To evaluate blood transfusion practice in hip and knee arthroplasty, the development of evidence based guidelines, their implementation and prospective analysis of change. An audit was carried out in 4 stages to complete the loop. Stage 1: Retrospective analysis of blood transfusion practice in primary and revision hip and knee arthroplasty. Review of case notes, nursing record, anaesthetic sheet and pathology results from a computer database was carried out. Rates of transfusion, patients’ body weight and height, peri-and post-operative blood loss, use of anticoagulants, drains, surgical approach, type of implant and cement, grade of surgeon and anaesthetist and haemodynamic complications were recorded. Stage 2: Literature search to develop evidence based guidelines for blood transfusion.

The data in stage 1 was evaluated in the light of those guidelines to determine appropriateness of blood transfusion. Stage 3: Dissemination and implementation of guidelines. Anaesthetic, Orthopaedic and audit departments were involved. Guidelines were presented, discussed, finalised and circulated.

Stage 4: Prospective re-evaluation of blood transfusion practice was undertaken. Parameters as in stage 1 plus documentation of reason for blood transfusion by the prescriber were recorded.

For stage 1, 97 Hip arthroplasty (86 primary and 11 revisions) and 119 Total knee arthroplasty procedures (109 primary and 10 revisions) over a period of 26 weeks were studied. Blood transfusion rate was 50.5% (49/97) in hip arthroplasty and 28.5% (34/119) in knee arthroplasty. Evidence based guidelines were developed. 55% transfusions were thought to be inappropriate in the light of guidelines. Following completion of stage 2 and 3, prospective audit of blood transfusion practice was initiated. It was compulsory for the person prescribing blood to document the indication. Data was collected on a daily basis for 15 weeks. In that period 150 joint replacements were undertaken. 77 hip arthroplasty (71 primary and 6 revisions) and 73 knee arthroplasty procedures (66 primary and 7 revisions) were undertaken. Blood transfusion rates for hip arthroplasty decreased to 18% (14/77) and for knee arthroplasty to 5.4% (4/73).

Overall transfusion rates decreased from 83/216 (38.5%) to 18/150 (12%) after implementation of guidelines. This represents an overall reduction of 68%.

Conclusion: A multidisciplinary approach and putting evidence based practice in place has resulted in reduced blood transfusion rates in hip and knee arthroplasty in our institution. We feel this change is an example of implementation of evidence-based practice.

Aim: To compare of strength of constructs using the newer and part specific nail systems: Polarus and European Humeral Nail with that using PHILOS and Conventional plate systems in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model.

Materials and Methods: A Biomechanical laboratory study was undertaken. Third generation composite Humerus model was used, with short e-glass epoxy fibres forming cortex and polyurethane cancellous core. Low-density polyurethane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were fixed using one of the implants- the Polarus nail, the European Humeral Nail, PHILOS Plate, Clover Leaf Plate or T-Plate. Following fixation samples were placed in a custom made jig to fix proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, torque to failure, cyclical compression and Compression loading to failure.

Results: The two Nail systems that are specifically designed for fixation of proximal humerus fracture provided significantly better fixation in all the test modalities. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression when compared to the other plates but the 2 nail systems were far superior. Locking screws did not ‘back off’ in any of the experiments involving the Polarus, European Humeral Nail and PHILOS construct, however ordinary screws used with the conventional plates did back off both in ‘torque and compression’ testing.

Conclusions: Polarus and European Humeral Nail constructs provide better stability in torque and compression as compared to PHILOS, which in turn is a more stable construct in comparison to conventional plating devices.

We have investigated the contaminating bacteria in primary hip arthroplasty and their sensitivity to the prophylactic antibiotics currently in use. Impressions (627) of the gloved hands of the surgical team in 50 total hip arthroplasties were obtained on blood agar. The gloves were changed after draping, at intervals of 20 minutes thereafter, and before using cement. Changes were also undertaken whenever a visible puncture was detected. The culture plates were incubated at 37°C for 48 hours. Isolates were identified and tested for sensitivity to flucloxacillin, which is a recognised indicator of sensitivity to cefuroxime. They were also tested against other agents depending upon their appearance on Gram staining.

We found contamination in 57 (9%) impressions and 106 bacterial isolates. Coagulase-negative staphylococci were seen most frequently (68.9%), but we also isolated Micrococcus (12.3%), diphtheroids (9.4%), Staphylococcus aureus (6.6%) and Escherichia coli (0.9%). Of the coagulase-negative staphylococci, only 52.1% were sensitive to flucloxacillin and therefore to cefuroxime. We believe that it is now appropriate to review the relevance of prophylaxis with cefuroxime and to consider the use of other agents.

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated.

Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.

Our study was undertaken to assess the inter- and intra-observer variability of the classification system of Sanders for calcaneal fractures. Five consultant orthopaedic surgeons with different subspecialty interests classified CT scans of 28 calcaneal fractures using this classification system. After six months, they reclassified the scans.

Kappa statistics were used to analyse the two groups. The interobserver variability of the classification system was 0.32 (95% confidence interval (CI) 0.26 to 0.38). The subclasses were then combined and assessment of agreement between the general classes as a whole gave a kappa value of 0.33 (95% CI 0.25 to 0.41). The mean kappa value for intra-observer variability of the classification system was 0.42 (95% CI 0.22 to 0.62). When the subclasses were combined, it was 0.45 (95% CI 0.21 to 0.65).

Our results show that, despite its popularity, the classification system of Sanders has only fair agreement among users.

Aims: Does PHILOS (Proximal Humeral Internal Locking system) construct provides better þxation than Clover leaf plate and T-plate in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model?Materials and Methods: Biomechanical laboratory study. Third generation composite Humerus model was used, with short e-glass epoxy þbres forming cortex and polyurethane cancellous core. Low density polyure-thane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were randomised to receive one of the implants. Following þxation samples were placed in a custom made jig to þx proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, Torque to failure, Cyclical compression and Compression loading to failure. Results were entered in a database. Results: PHILOS provided signiþcantly better þxation in ÔTorque to failureñ experiment. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression. Locking screws did not Ôback offñ in any of the experiments involving PHILOS construct, however ordinary screws did back off both in Ôtoque and compressionñ testing. Conclusions: PHILOS construct provides better stability in Torque and compression as compared to conventional plating devices, in an osteoporotic bone model.

Aims: To derive a formula for blood loss estimation and also to assess if high body weight is protective against blood transfusion following elective arthroplasty? Methods: Retrospective study of patients undergoing elective primary hip arthroplasty. Weight of the patient, pre and postoperative haematological investigations and details of blood transfusion were collected. Results: Formula for blood loss estimation was derived, Blood loss= ( 70 x body weight in Kg) x (drop in haematocrit) (Pre-op haematocrit+ post-op haematocrit)Ö2

The mean blood loss in 86 patients was 1631ml. Mean blood lost/Kg body weight was 22.6ml. 36/86 patients had < 21ml/kg (42%) and 50/86 had > 21ml/kg blood loss (58%). 21 ml/kg represents 30% loss of blood volume. Patients losing > 21ml/kg blood had signiþcantly higher blood transfusion rates (Chi squared test; χ2(1)= 5.50, p=0.02).

The amount of blood loss increases with weight of patients (p< 0.01). The rates of transfusion in patients with ≤ 72 kg weight (circulatory volume ~ 5 litre) was 51% (23/45), and in patients > 72 kg it was 36.5% (15/41). Rates of transfusion were related to pre-op Hb but were unaffected by gender, age, cemented/uncemented prosthesis, surgical approach, type of prosthesis, use of drains, grade of surgeon, type of anaesthetic. Conclusion: Calculated blood loss > 21ml/kg and patientñs low body weight are associated with increased risk of blood transfusion.

We describe a 15-year-old boy with a posterior dislocation of the hip, fracture of the posterior column of the acetabulum and separation of the femoral capital epiphysis. To our knowledge no previous case in a child has been reported. Such high-energy injuries are extremely rare, and a poor outcome is expected.

We advocate early referral to a specialised tertiary centre, and the use of a modification of Delbet’s classification to reflect the complexity and displacement which may occur with this injury.