Aim We have prospectively investigated the effect of tranexamic acid in reducing blood loss and transfusion requirements in primary and revision total hip arthroplasty in a comparative study.

Patients and Methods In the study group, tranexamic acid was given half an hour before the skin incision. (10 mg/kg as an intravenous bolus, followed by 10 mg/kg as intravenous infusion over 6 hours). We recorded the haemoglobin level preoperatively and prior to discharge, and number of units of blood transfused. The total peri-operative blood loss and the fall in haemoglobin after surgery was calculated in consultation with our haematologist. There were 9 primary and 17 revision hip replacements in the study group. We compared the results with a control group of 10 primary and 20 revisions performed during a similar period, without tranexamic acid, recording identical parameters. Thrombo-embolic and wound complications were recorded.

Results Patients receiving tranexamic acid had a mean fall in haemoglobin level of 3.1 g/dl and mean blood loss of 4.1 litres. The control group operated without tranexamic acid had a mean fall in the level of haemoglobin of 3.7 g/dl, and the mean blood loss 5.4 litres. The average number of units of blood transfusion required was 0.77 per patient in the study group compared to 2.03 per patient in the control group. The differences were significant (p value of 0.05). There was no increase in the incidence of complications such as deep vein thrombosis, pulmonary embolism, or wound problems in the study group.

Conclusion Tranexamic acid given prior to surgery reduces blood loss and need for blood transfusion, not only in primary but also in revision hip arthroplasty, without any increase in the rate of thrombo-embolic complications.

Aim: To review the results and complications of revision of the socket in total hip arthroplasty using rim mesh and impaction allograft for reconstruction of segmental and complex defects

Patients & Methods: 43 patients who underwent a revision of the socket in 47 total hip replacements were retrospectively reviewed over a 3 ½ year period. All the patients had segmental or complex bone loss around the acetabulum which was reconstructed using Stryker Howmedica rim mesh, impaction bone grafting and a cemented cup through the posterior approach. Final analysis included clinical review at latest follow-up, radiological evaluation to assess graft incorporation and socket migration and any other complications.

Results: All patients were followed up for a mean period of 14.2 months (range: 2 months-33 months). The mean age at surgery was 58.2 yrs. There were 14 males and 29 females. This was a re-revision in 5 patients. The most common indication for revision was aseptic socket loosening with migration in 39 patients. One patient had a two stage revision for infection, one had socket fracture, and two patients had collapse of bulk graft and socket migration. Superior segmental defect of varying sizes were present in all patients, in addition to which there were central deficiencies, anterior and/or posterior column deficiencies and complex defects. 4 patients had post-operative dislocation, 1 had significant limb length discrepancy, 1 had infection and 1 had transient sciatic nerve palsy. At the latest follow-up all patients had good graft incorporation and no socket migration.

Conclusion: Rim mesh helps in containing a segmental defect of acetabulum provides good immediate support for impacted graft and socket and has produced good early results. However, long term follow-up is necessary to determine the outcome of this construct.

Aim: To review results and complications of revision knee replacements.

Materials and Methods: We retrospectively reviewed 41 cases of cemented revision knee arthroplasty in 39 patients (15 male, 24 female) performed between 1993 and 2003. Data regarding clinical and functional outcomes and complications was recorded.

Results: Mean age at index (revision) operation was 67.8 years (32 to 86) and mean follow-up was 6.8 years (1.5 to 12). Average time to revision was 80 months (9 months to 23 years).

The indication for revision was aseptic loosening in 16 cases, and deep sepsis in 13 cases, (12 were done in 2 stages). Others included polyethylene wear in 4 knees, instability in 2, and 1 each of peri-prosthetic fracture, implant breakage and pain of undetermined origin. 3 revisions were performed for failed Link Lubinus patello-femoral replacement. Mean interval between staged procedures for sepsis was 2 months.

Reconstruction was performed using the Kinemax Revision system with the use of augments and stems. The modular rotating hinge was used in 4 cases. Surgical exposure included additional lateral release in 7 cases, tibial tubercle osteotomy in 4 and quadriceps snip in one.

Complications: Included 1 post-operative death due to haematemesis and 2 non-fatal cardiac complications. 1 patient was re-revised for aseptic loosening at 3.5 years, 1 needed an above knee amputation for intractable sepsis after multiple failed reconstructions and 1 is awaiting patellar revision.

At latest review, 7 patients had died due to unrelated causes with a pain free functioning knee prosthesis. Of the remaining 31, 26 patients had none or minimal pain. 21 were independently mobile with a satisfactory range of motion.10 patients needed a walking stick.

Conclusion: Revision total knee replacement can give satisfactory results in the short to medium term, although the complication rate can be significant. The procedure should be performed in specialist units. Revision in 2 stages for sepsis resulted in satisfactory control of infection in our study.

Aim: To review treatment, results and complications of pelvic ring injuries.

Materials & Methods: We reviewed 39 pelvic ring injuries, mean age 37 years, referred to a tertiary unit, with mean follow up 19 months (6 to 60). Data regarding type of fracture, associated injuries, treatment, injury surgery interval, complications and outcome was documented.

Results: Vehicular accidents in 21 were the commonest mechanism of injury and 30 had vertical shear fractures. There were 4 associated head injuries, 5 chest, 4 maxillo-facial, 4 perineal/ vaginal tears, 7 urological, 1 anorectal, 2 each of abdominal and ophthalmic, and 1 each of vascular, spine and brachial plexus injuries. Also there were 15 skeletal fractures, 12 soft tissue injuries and 11 associated acetabular fractures of which 8 needed fixation, and 17 had lumbosacral plexus injuries. 6 compound pelvic fractures were treated with debridement, fixation and early life saving bowel diversion. 19 patients had anterior external fixators, 9 were applied elsewhere for resuscitation.

Complications: There were 10 systemic complications, 4 ARDS, 2 wound infections and 1 colovesical fistula, 1 infected pubic plate, and 3 late inguinal hernias. 8 patients had pin track infections, and 5 iatrogenic problems including 2 nerve lesions, 2 vascular injuries and 1 bladder rupture, none of which left any residual problem.

Results: 20 patients had no pain, 31 were fully mobile without aids, and 22 had returned to original level of activity. 6 complained of sexual dysfunction, and 1 had double incontinence. 6 patients were on disability allowance, and 10 had full recovery of lumbosacral plexus injury.

Conclusion: Severe associated injuries and soft tissue trauma significantly affect outcome and complications, inspite of sound bony fixation and healing, and multi-disciplinary management is obligatory. Posterior ring lesions were often underestimated, and anterior external fixation alone can make them worse. Early colostomy is lifesaving in compound pelvic fractures. Early involvement of a specialist surgeon is desirable for optimal outcome, which can be achieved in most patients.

Aims: The aim of this study was to þnd out if undisplaced displaced distal radial fractures require plaster immobilisation. Methods: In this prospective study, undisplaced distal radial fractures were divided into two groups; plaster immobilisation was used for one group while removable volar splint was used for the other group. Follow up was at six weeks, three months and six months. Patients were assessed by clinical examination, grip strength, radiological assessment, EQ-5D and a Short Form 12 questionnaire. Results: At 3 months, no difference was found between the two groups in clinical evaluation, radiological assessment, the functional outcome, grip strength, and visual analogue score for pain. Conclusions: We conclude that undisplaced distal radius fractures can probably be treated with out a plaster cast and put straight into wrist orthosis.

Aim: We report results of surgical treatment of acetabular fractures and highlight the importance of single approach for complex fractures. Methods: 50 acetabular fractures referred to a specialist unit between 1994 and 1999 were treated surgically with anatomic reduction and internal þxation. Mean follow up was 32.3 months (14 to 67). Patients were regularly followed up in a special pelvic clinic for documentation of Harris hip score (pain, function, movement, activity), and radiological evidence of healing, avascular necrosis or other complications. Results: 18 patients were treated with the anterior ilioinguinal approach for 11 both- column, 3 anterior column, 3 transverse fractures and 1 central dislocation. 28 patients had posterior Kocher-Langenbeck approach for 17 posterior fracture dislocations, 2 both-column, 6 posterior wall and 1 each of transverse, posterior column and Tshaped fracture. 4 needed combined anterior- posterior or extensile triradiate approach due to comminution or delayed referral. Mean hospital stay was 24.7 days and mean injury surgery interval was 10.8 days. Of the 42 transfers from other units, 7 had surgery after 3 weeks from the injury. Outcome: 47 patients were followed up. Mean Harris hip score was 82.7 (31–100) for the posterior approach group, and 78.1 (27–99) for anterior approach group.3 patients needed total hip arthroplasty for secondary arthritis. Grade3–4 Brooker ectopic bone was noted in 3 posterior and 1 anterior approaches. There was no infection or avascular necrosis. Conclusion: Single approach surgery was possible in 46 patients and had a low rate of complications. Poor outcome occurred in highly comminuted fractures or with a delay in referral. Anterior ilioinguinal approach, although demanding, was the approach of choice for both column fractures. Early referral to a specialist unit is recommended.

Aims: To compare the results between intramedullary hip screw (IMHS) and dynamic hip screw (DHS) regarding operative time and radiation exposure time Methods:We reviewed radiation exposure times obtained during the fixation of 281 extracapsular proximal femoral fractures. Dynamic hip screw was used in 148, and intramedullary hip screw was used in 133. Results: The results showed that there was no statistical difference in ionising radiation exposure in closed reduction of these fractures regardless of fracture configuration or surgical experience of the surgeon, but there was a statistical difference in implant insertion time and radiation exposure (p= < 0.05). Conclusions: We conclude that intramed-ullary implant takes more radiation exposure because they take more time for insertion, which is irrespective of surgical experience and complexity of fracture.

Aims: Dynamic hip screw (DHS) is a common implant used for extracapsular fracture neck of femur. Accurate placement of the guide wires for the DHS insertion is the most important surgical step. In order to improve precision and accuracy of the guide wire placement, Computer Assisted Orthopaedic Surgery System (CAOSS) was used which was developed at the University of Hull. Early clinical experience in 14 cases is presented. Methods: CAOSS helps in surgical planning and aid surgeons for accurate guide wire placement into femoral neck. After fracture reduction, intraoperative computer based surgical planning was performed using one ßuoroscopic image in two planes each. A trajectory obtained thus helped surgeon to place a guide wire along with the required course under the computer guidance. Results: CAOSS system was used on 11 patients for guide wire placement. Intraoperative ßuoroscopic images of all the patients showed accurate position of the guide wire both in AP and lateral planes. Only 4 ßuoroscopic images were required during the surgical procedure in total, both pre and post guide wire insertion. Conclusions: The computer aided surgery used in guide wire placement for dynamic hip screw insertion proves to be accurate and reliable. It also reduces ionisation radiation exposure to the surgeon, patients and theatre personnel.

Aim: We audited medical complications after revision hip arthroplasty, in elderly and young patients and correlated its occurrence to the preoperative medical status. Methods: 104 revision hip replacements in 100 patients (mean age 71.5 years) were followed up for a mean of 33.9 months. (9–67). 49 were above 75 years of age. The American Society of Anaesthetists grading system was used to assess preoperative medical fitness. 50% patients were in ASA grade III. Medical complications in the first 3 postoperative months were classified into major, moderate and minor (Phillips). There were pre-existing cardiac problems in 57, COPD in 13, vascular disease in 7, cerebro vascular disease in 7, previous DVT in 6 and renal/endocrine problems in 16. Results: Overall medical complication rate was 35% (7% major, 14% moderate and 14% minor). The rate in elderly patients was 21%. There was 1 postoperative death due to cardiac reasons at 2 months. There were cardiac complications in 23%, anaemia in 17%, respiratory problems in 10%, hematemesis in 7%, renal in 7%, circulatory in 7%, deep vein thrombosis in 5%, pulmonary thromboembolism in 5%. Mean hospital stay was 17.8 days. 83 patients had no pain, 88 were independent, and 7 had poor mobility. 85% were satisfied with the operation. The major medical complications were not significantly higher in elderly than in younger patients. Conclusion ASA grade correlated positively with frequency and severity of medical complications (Fisher exact test p < 0.001). The occurrence was independent of the age of the patient (p=0.106). Revision hip arthroplasty was well-tolerated in elderly patients and age alone is not a contra-indication. This compared favourably with other reported series. Good anaesthetic and medical support is vital.

Aim: 40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67.3 (48–87) years and the mean follow up 50 (8–134) months. Each patient had undergone at least 1 operation prior to the index arthroplasty (1–10). 27 elbows were ßail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. Methods: A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a Snap þt Souter Strathclyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. Results: At review 38 elbows had no or mild pain, 2 moderate, and no patient with severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in 1 and curettage and bone grafting of a cement granuloma in 1. One patient with a Charcot joint developed a non- union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition 6 had delayed wound healing, 2 ulnar nerve symptoms and 2 triceps weakness. Conclusions: In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a ßail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.

Aim: The aim of the study was to analyse the long-term follow-up of patients who were treated with chemonucleolysis for single level disc prolapse. Method: In our retrospective study we reviewed 112 cases that underwent chemonucleolysis for single level lumber disc herniation during the period of 1988–1996. Mean follow up was 9.5 years. In order to estimate the functional outcome of chemonucleolysis Oswestry Disability Index questionnaire was used. Results: An excellent or good response occurred in 79 patients (70.5%); 12 patients (10.7%) showed moderate response with minimal disability. Treatment failed in 21 patients (18.5%) who showed poor response and 12 of these 21 patients went for surgery within a mean period of 6 months. One patient had surgery at different level than chemonucleolysis. There was only one incident of procedure termination because of epidural contrast leak. There was no case of anaphylaxis or discitis. Conclusion: We conclude on the basis of our results that chemonucleolysis is a safe and effective treatment modality for lumber disc herniation in carefully selected patients.

Aim: To assess the radiological appearance and subsequent behaviour of impacted allograft in revision hip surgery using the Charnley femoral prosthesis. Method: A prospective radiological study of hip arthroplasty revised for aseptic loosening with femoral bone loss was performed. Preoperative bone loss was assessed using the Endo Klinik grading. Impaction grafting with fresh frozen femoral head allograft and the Charnley stem was used in all cases. Postoperative X-rays and annual review films were examined for graft distribution, cortical repair and stem subsidence. Graft consolidation and cortical repair was assessed. Results: Twenty cases were followed up for 6 to 8 years. Fourteen cases had even distribution of graft and 6 had deficiency in one Gruen zone. Graft consolidation was identified in all cases at one year. Cortical repair was noted in 14 out of 15 Endo Klinik III cases. One patient died after 2 years and 9 months. Two stems have subsided by more than 5 mm and are asymptomatic. Two cases with subsidence have been revised. All cases with subsidence were associated with graft deficiency in Gruen zone II or III on the postoperative X-ray. Conclusions: Good initial graft distribution on the postoperative X-ray is associated with graft consolidation, cortical repair and minimal stem subsidence. Initial deficiency in graft distribution is associated with stem subsidence and revision. These findings highlight the importance of a surgical technique, which ensures even graft distribution.

Aims: Dynamic hip screw (DHS) is a common implant used for extracapsular fracture neck of femur. Accurate placement of the guide wires for the DHS insertion is the most important surgical step. In order to improve precision and accuracy of the guide wire placement, Computer Assisted Orthopaedic Surgery System (CAOSS) was used , which was developed at the University of Hull.

Methods: CAOSS helps in surgical planning and aid surgeons for accurate guide wire placement into femoral neck. After fracture reduction, intra-operative computer based surgical planning was performed using one fluoroscopic image in two planes each. A trajectory obtained thus helped surgeon to place a guide wire along with the required course under the computer guidance.

Results: CAOSS system was used on 11 patients for guide wire placement. Intra-operative fluoroscopic images of all the patients showed accurate position of the guide wire both in AP and lateral planes. In theory only 4 fluoroscopic images are required during this surgical procedure in total. But in practice, more than 4 were required depending upon the experience of the radiographer. None of the patient had any intra-operative complication. Conclusions: The computer aided surgery was found to be safe, accurate and reliable for guide wire placement for dynamic hip screw insertion.

Rotator cuff pathologies are related with higher incidence of morbidity in the modern society in young patients. Although it is well known that rotator cuff is sandwiched between the acromion and humeral head during various movements of the shoulder joint, only few studies have investigated this looking at the humeral head as a culprit for the rotator cuff pathology.

We carried out the cadaveric study of 15 shoulder joints to find out the influence of the humeral head anatomy on the rotator cuff pathology. We dissected 15 shoulder joints and looked at the rotator cuff tears. All the specimens were examined and photographed digitally from the superior aspect of shoulder joint. All these images were entered into a computer and using special software, we carried out 3D reconstruction of these images. With this software, the outermost point of intersection of humerus head with acromion decided. We calculated the area of the humeral head in an outside the acromion and correlated with the rotator cuff tear.

We found that the area of the humeral head outside the acromion is variable, ranging from 18% to 50% of diameter of humeral head (mean 34%, median 33%, mode 20%, 33%, 45%). When the area of humerus head outside the acromion is less than 32% of the diameter of head (i.e. humerus head was more under the acromion and less outside the outer most point of acromion), those specimens had either incomplete or complete rotator cuff tear.

We conclude that when the area of humeral head, covered under the acromion is more than 68% of the diameter of the head, they have more chances of developing rotator cuff pathology as compare to other individual.

The results of hip injections for 63 patients with hip pain are presented. Injection of 80mg of methylprednisolone and bupivacaine by an anterior approach was performed with x-ray screening. Patients were noted as having either a normal x-ray (10), mild osteoarthritis (21), moderate osteoarthritis (13) and severe osteoarthritis (19), those in the severe group were generally unfit for hip surgery. Outcome was judged by an Oxford hip score, which was calculated pre-injection, at one month, and at three months. At three months all with a normal x-ray were improved, 19 with mild changes were improved 2 deteriorated, 9 with moderate changes improved, 2 stayed the same, 2 deteriorated and 13 with severe changes were improved, 4 deteriorated and 2 were unchanged. Improvements were with pain scores not function. Of those improved all thought the procedure worthwhile. Two patients described numbness and weakness at the anterior thigh area, which recovered quickly. We feel that this is a useful technique to give symptomatic relief in-patients not suitable for hip replacement.