We explored the association of post-operative pyrexia following hip arthroplasty and the development of deep infection Method: The postoperative temperature records of 80 patient’s following primary hip replacement were retrospectively analysed. Thirty-one patients had revision surgery at a mean time interval of 37.2 months (range 5–74 months) for confirmed deep prosthetic infection. The control group of patients were asymptomatic at a mean follow-up of 31.5 months. There were 28 patients with an uneventful clinical outcome following surgery and 21 patients who had developed a systemic infection during their stay in hospital. The maximum daily temperature of each patient was recorded. Results: The mean peak temperature of patients with deep prosthetic infection was significantly lower then patients with a systemic infection or a normal clinical recovery following surgery (p=0.01). The difference between the peak post-operative temperature and the preoperative temperature was also significantly lower in patients who subsequently required revision surgery for prosthetic infection (p=0.007). Conclusion: Patients with deep prosthetic infection have a lower pyrexia response then patients with either an uneventful clinical recovery or the development of a systemic infection following total hip replacement. Pyrexia is part of the acute phase response following surgery is mediated by cytokines including IL-1 and IL-6, which are also involved in activation of the patients cellular and humoral immune response. A low pyrexia response following surgery may therefore also be suggestive of reduced acute phase response to the potential wound contamination produced during surgery with a consequence of subsequent prosthetic infection.

Aims: To investigate whether blood transfusion practice in primary total knee replacement (TKR) was being managed appropriately, and to assess the cost effectiveness of pre-operative autologous donation (PAD). Methods: A retrospective survey of blood transfusion practice was conducted for all TKR. The unit has an established PAD service with over 60% uptake for suitable candidates. An analysis of all pre-operative and post-operative haemoglobin concentrations (Hb) was performed. Using Hb concentration of 8 g/dl or 9 g/dl as the transfusion criteria, the total units of blood used, saved or discarded was calculated. Results: 174 TKR were performed, 84 (48%) patients were transfused. 52 patients (117 units) received allogenic blood, 35 patients (61 units) received PAD blood, 8 patients received both. 60 units (50%) of PAD were discarded. Using a level of Hb of 8 g/dl, 46 patients (96 units) would have received allogenic blood, 30 patients (51 units) would have received PAD blood and 7 patients both. 70 units (58%) of PAD would have been discarded. Using a level of Hb of 9 g/dl, 35 patients (69 units) would have received allogenic blood, 22 patients (36 units) would have received PAD blood and 6 patients both. 85 units (70%) of PAD would have been discarded. If the transfusion threshold used were < 8 g/dl and < 9 g/dl, the potential saving was estimated at approximately £9578 and £6884 respectively. Conclusions: PAD service is considerably more expensive than allogenic blood. With high percentages of PAD being discarded, the service is not cost effective. Substantial saving can be achieved with a þrmer transfusion policy for post-operative patients.

The metabolic response of trauma may mimic infection and the reliability of serological parameters for diagnosing infection may be questionable. We prospectively assessed the changes in the acute inflammatory markers, febrile response and the immune profiles of 101 patients following primary hip arthroplasty and their association with infection. Method: The clinical outcome of 101 patients was monitored. Serological analysis was performed pre-operatively and on the second and 8th post-operative day as well as in an out patient clinic 6 weeks following surgery. The serological markers included total white blood cell count along with T and B lymphocyte function. Levels of CD4, CD8 and CD56 were analysed for T helper, T Cytotoxic cell and Natural Killer cell activity. Inflammatory makers included plasma viscosity and CRP. Serological titres of Staph. Aureus and Staph. Epidermis were performed preoperatively and on day 8 and week 6 following surgery. Results: post-operative complications included 19 UTI, 11 chest infections and three URTI and six a confirmed deep vein thrombosis. Twenty patients had elevated ASO titres and 19 patients had raised Staph. Epidermis titres. Statistical comparison of WBC, Plasma viscosity, temperature profiles and T helper, T cytotoxic cell and NK cell assays is not different between patients with and without systemic infection or raised titres of Staph. Aureus or Staph. Epidermis. Conclusion: The acute phase responses following surgery and metabolic response to trauma obscures the changes seen in infective complications up to six weeks post-operatively. Their use in diagnosing infection appears unjustified.

Aims: To report the outcome of secondary patellar resurfacing in patients with chronic anterior knee pain following primary total knee replacement. Methods: A total of twenty patients identified over a 10-year period from 623 patients managed without patellar replacement during primary knee arthroplasty were included and evaluated pre and postoperatively using the American Knee Society (AKS) score, as well as by radiological analysis. Results: The mean follow up was 36.1 months (range 12–104 months). The mean knee score improved from 46.7 to 62.2 points while the mean functional score increased from 44.7 to 52.2 points. Only 44.5% of the patients reported some improvement whereas the remaining reported no change or deterioration. Postoperative radiographic alignment of the primary knee arthroplasty did not influence outcome of secondary patellar resurfacing. Complications were noted in 6 of the 20 patients including patella fracture, patella instability and loss of a range of movement. Conclusions: Anterior knee pain following knee arthroplasty remains a difficult condition to manage and secondary resurfacing of the patella is clearly not to be advocated in all patients since it may well increase patient dissatisfaction and hasten revision.

Introduction: While the early period of distraction osteogenesis has been extensively investigated, there are no data describing the long-term morphology of the regenerate. Patients and Methods: We performed MRI scans to ten adults, seven of which had bone transport for an osseous defect while further three had lengthening for limb length discrepancy. Follow up ranged between 14 and 43 months (mean: 29 months) following the removal of the external fixator. The perimeter, cross sectional area, volume and the mean signal intensity was calculated from the obtained T1 weighted axial images. Values were compared with the contralateral tibia that acted as control. Results: All cases that had bone transport increased the volume of the tibia from 15.3% up to 50.8%. The regenerated segment was noted to have expanded significantly (p< 0.0001) in all cases. Mean signal intensity in the regenerate decreased in seven cases significantly (p< 0.0001) suggesting increase content of unhydrated tissue such as bone and collagen. The cross sectional surface of the transported segment was increased in all cases (p< 0.008), which associated increase in the signal intensity (p< 0.003). Finally in cases that underwent bone transport, the docking site was noted to be obstructed by unhydrated tissue. Conclusions: Contrary to previous claims, the post-distraction osteogenesis tibia is far from normal, consisting of areas with potentially different biomechanical properties. Recognition of these changes is essential not only for appropriate preoperative counselling but also for considering treatment modalities in case of a fracture.

Pyrexia in the post-operative setting has often been associated with a possible systemic or wound infection. We assessed whether there is any justification for our concern regarding post-operative pyrexia following hip arthroplasty and subsequent deep prosthetic infection.

We undertook an assessment of the clinical outcome of 97 sequential patients who underwent 103 primary hip arthroplasty for primary osteoarthritis replacements. Daily temperature and systemic complications in the post-operative period were recorded. Clinical outcome was measured using an Oxford hip questionnaire.

Patients had a mean follow-up of 5.2 years (range 3.5–7.2years)

We reviewed the postoperative temperature records of 80 patients who had undergone primary total hip replacement. Thirty-one patients had required revision surgery at a mean time interval of 37.2 months (range 5–74 months) for confirmed deep prosthetic infection. The remaining Forty-nine patients were asymptomatic at a mean follow-up of 31.5 months.

Study 1

Post-operative pyrexia of 38 degrees Celsius was present in 51% of patients undergoing primary hip replacement in the first post-operative week but in 21.1% no etiological cause could be identified. Clinical outcome measured by an Oxford hip questionnaire was not influenced by the post-operative temperature pattern.

Study 2

The mean peak temperature on the first post-operative day was significantly lower in patients with deep prosthetic infection then patients with a clinically normal outcome (p=0.01).

Post-operative pyrexia is clearly not uncommon following primary arthroplasty and its presence should not be regarded as detrimental. Pyrexia in the postoperative setting is a component of the acute phase response to trauma and study 2 demonstrates patients who develop a low-grade infection following arthroplasty may have a diminished febrile response to surgical trauma which may be an indirect representation of a diminished immune response to surgical trauma or infection

Fatal pulmonary embolism (PE) after total hip replacement (THR) is a major concern to all orthopaedic surgeons. Our intention was to ascertain death rates and deaths due to PE following total hip replacement where chemical thromboprophylaxis was not used routinely.

We determined retrospectively, the postoperative mortality and fatal pulmonary embolism rates in 1671 consecutive primary total hop replacements in 1547 patients performed as staged procedures between January 1997 and April 2000 at an orthopaedic hospital. The minimum follow-up period was six weeks period after surgery at an orthopaedic hospital. Patients were traced by questionnaires, outpatient appointments and by telephone. Post-mortem records were used to verify cause of death. Follow-up was 100%. The death rate from PE was 0. 12% (CI 0. 03% – 0. 44%) and the all-cause mortality rate was 0. 36% (CI 0. 16% – 0. 78%). All deaths were within the first 10 days during the initial hospital stay. The patient mortality was compared with the population mortality for England and Wales, using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0. 81. We observed a lower mortality in females (SMR=0. 43) but a higher mortality in males (SMR=1. 44) during the first 42 postoperative days compared to the general population.

Fatal PE after THR without routine chemical thromboprophylaxis is very uncommon. The death rate in patients undergoing THR appears to be lower than that in the general population.

Cross match practice for patients with femoral neck fractures continue to cause concern due to a failure of compliance to the existing protocols. We addressed this issue by conducting a number of studies over three years and we report the summation of the studies and demonstrate the reasons for the poor compliance. We provide a simple and effective protocol that has helped reduce preoperative cross matching of femoral neck fractures from 71% to 16.7% two years after its introduction.

Study 1

Retrospective review of the cross-match practice for 240 femoral neck fractures and reviewed the changes in pre-operative and post-operative haemoglobin levels and association with surgical procedure.

Study 2.

Postal questionnaire of 129 anaesthetic and orthopaedic trainees assessing the perceived cross-match requirements of patients with femoral neck fractures based on preoperative haemoglobin values between 8–13g/dl. In addition reviewed the source of trainees perceptions and practice

Study 3

Review of the efficiency of the cross-match protocol two years after its introduction Results

Study 1

71% patients with femoral neck fractures were cross-matched at admission but only 29% of the patients were subsequently transfused. From the 384 units of blood ordered at admission 230 were returned unused. Inter-trochanteric fractures had a mean blood loss of 3.1g/dl (range 1.5–7.2g/dl) following surgery in comparison to a mean loss of 1.7g/dl (0.9–3.4g/dl) for patients with displaced subcapital fractures

Study 2

Orthopaedic trainees at all levels of training requested more blood then their anaesthetic counterparts for patients with femoral neck fractures. There was misconceptions regarding blood loss following surgery amongst all trainees and only 14.3% trainees used existing literature to guide their cross-match practice where as 53.4% devised protocols based on their own or colleagues’ experience.

Study 3

Cross-match protocol was working effectively. Only 16.7% of the patients with femoral neck fractures were cross-matched on admission.

Conclusion

Cross-match recommendations fail to influence trainees. In order to address this we produced a protocol that does not rely on orthopaedic trainees. The haematology MLSO provides the appropriate amount of preoperative blood for the patient based on our finding of blood loss of different fracture patterns and the patients’ preoperative haemoglobin level. Our results show our protocol is still effective two years following its introduction despite numerous changes in trainees during this period.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared test.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients and the production of pre-operative literature.

This study was performed to evaluate the pre-operative concerns of patients undergoing total knee or hip replacement surgery.

A cross-sectional study of 370 patients was performed. The patients completed a postal questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). SF-12 and Oxford knee or hip scores were also calculated. Analysis was carried out using chi-squared tests on SPSS.

217 questionnaires were returned. The results showed that the greatest concern for patients was cancellation of their operation. This was followed by failure of the operation to reduce pain, loss of a limb and joint infection. Concerns regarding scar problems, nursing care and preoperative tests were the lowest.

Women showed statistically significant greater concerns in 9 areas. Younger patients (age< 65) showed increased concerns in 8 areas. Patients who had previously undergone joint replacement were less concerned than those who had not had previous lower limb joint replacements for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip replacement were more concerned about dislocation, dressing and returning to work (all p< 0.05). The mean Oxford Knee or Hip Score was 42.96 and 45.12 respectively (scale 12–60, 60 being most severe symptoms). The mean SF-12 scores were 41.14 for the mental component and 28.70 for the physical component score (scale 0–100, 100 representing greatest level of good health).

The mean level of concern is low at 1.9 (scale 1 to 4). It is encouraging that patients who have had a previous joint replacement are generally less concerned. Possible reasons for increased concerns amongst women and younger patients are discussed. SF-12 and Oxford Knee/Hip Scores are comparable with other studies.

In conclusion, this study provides useful information for the preoperative counselling of patients, production of preoperative literature and for improving the service we offer to our patients.

Background: While generally aware about other infectious diseases, few realize the threats posed by Hepatitis C. We assessed if the Orthopedic surgery residents have adequate knowledge and wheather they take necessary precautions when exposed clinically to Hepatitis C.

Methods: A pre coded structured questionnaire was administered to Orthopedic surgery residents from three provinces and seven cities of Pakistan, who were participating in the Annual Orthopedic Review Course at the Aga Khan University hospital. Unprompted questions, focused on key knowledge issues, while beliefs and practices were assessed through knowledge and attitude towards Hepatitis C infectivity, complications, therapeutic modalities, actual precautions taken by them while handling body secretions of the patients. and their reading habbits about the literature of this disease.

Results: The median number of surgeries participated in, by the forty-three residents was 150 in the last one year. Though 83% knew that there was no vaccine for HCV, majority (66%) was unaware that it is a sexually transmitted disease and 82% did not know about its possibility of being transmitted perinatally. Eighty-eight percent knew about its transmission through a needle prick injury but 71% of the residents were unaware of the fact that in the case of the needle prick, highest risk of acquisition is of HCV when compared to HBV and HIV. In practices, 74% were vaccinated for HBV. When handling a known case of HCV, 87% used an extra pair of gloves while only 50% took extra care with needles. Median number of needle pricks was one in last one year. Only 16% knew the serostatus of the patients they received injury from. Only 28% of the residents knew their own serostatus for HCV compared to 60% for HBV. 60% of these residents were in habit of handling needles with their hands. Knowledge of HCV did not diff

Conclusion: Changing the attitude of the health care workers towards HCV has become increasingly important. We suggest that all new residents should be given a pretest, a lecture, a demonstration of the standard precautions and infection control procedures with post test, in the beginning of their carriers.

Aim: To determine retrospectively the post-operative mortality and fatal pulmonary embolism (PE) rates in 936 consecutive primary total knee replacements (TKR) in the three month period after surgery where chemical thromboprophylaxis was not routinely used.

Methods: Operations were performed over a period of eleven years by eight different senior orthopaedic surgeons on 248 men and 525 women. One hundred and sixty three patients had bilateral TKRs and the mean age at the time of operation was similar (69.4 and 72.2 years respectively). Patients were traced by out-patient appointments, telephone and through their general practitioners (GPs). Post-mortem examinations were used to verify cause of death in all save three of the cases. All but one of the patients were followed up.

Results: There were no deaths from PE confirmed by post-mortem examinations. As three patients were certified dead without post-mortem examination and one patient could not be traced this meant that, at worst, our fatal PE rate was 0.43% (4/936; CI 0.14%–1.17%). The all-cause mortality rate was 0.64% (6/936; CI 0.26%–0.46%) (Table 1). The patient mortality was compared with the population mortality of England and Wales using standardised mortality ratios (SMRs). The SMR for both sexes combined was 0.74 (CI 0.29–1.52). We observed a lower mortality in females SMR = 0.67 and males SMR = 0.84 during the first three post-operative months than compared to the general population.

Conclusion: Fatal pulmonary embolism after total knee replacement without routine chemical thromboprophylaxis is uncommon. The overall death rate in this series of patients undergoing total knee replacement appears to be lower than that in the general population.