Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance. 846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System^® foot-pump units (Orthofix Vascular Novamedix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone. Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05). In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance.

Background: There has been much interest recently in reducing the length of inpatient stay after hip and knee arthroplasty and much of the relevant literature has linked this to minimally invasive surgery. Orthopaedic departments are often under great pressure to reduce inpatient stay in order to increase throughput of patients. However it is incumbent on those of us responsible for patient care to ensure that systems are in place to maintain safety.

Patients and Methods:We looked at a 6 month period of early discharge with a dedicated ‘Accelerated Discharge Team’ (A.T.T.) at our institution. The team consisted of three nurses, two physiotherapists and two ‘technical instructors’. All patients undergoing hip or knee arthroplasty were assessed pre-operatively and post-operatively for admission to the care of the A.T.T. against fixed criteria. Patients were visited at home on the day of discharge and every day until released from the care of the team. 333 patients underwent lower limb arthroplasty during the study period of which 305 (91.6%) were admitted to the care of the A.T.T.

Results: The mean lengths of stay for primary hip and knee replacements were 3.43 and 3.30 days respectively. The mean for revision hip and knee were 5.75 and 3.29 days respectively. 66% (95% C.I. 57%–74%) of patients undergoing primary hip arthroplasty went home by 3 days and 91% (95% C.I. 85%–95%) by 4 days. 73% (95% C.I. 64%–81%) of patients undergoing total knee arthroplasty went home by 3 days and 93% (95% C.I. 87%–97%) by 4 days. The most common reasons for delay were: social reasons or living alone; low blood pressure or haemoglobin level; difficulty walking. Of the 305 patients, 12 (4%) were readmitted to hospital within 6 weeks of discharge, 2 of these patients (1%) were still under the care of the A.T.T. Almost 90% of patients responded to a satisfaction survey. 94.2% of those responding indicated that they would use the A.T.T. scheme again.

Discussion: Other authors have linked early discharge to minimally invasive surgery or to special anaesthetic/ analgesic techniques. It has also been shown that both carepathways and patient education protocols can reduce length of stay. In the year before implementing the A.T.T. the mean stay for primary hip and knee replacements was over 9 days. We were able to reduce this to less than 3.5 days for over 90% of our patients during the study period. This was achieved safely and without any special surgical or anaesthetic techniques. The total cost of the scheme was just under £100 000 for the 6 month period. We estimate that 2000 bed days were saved during the same period. This is cost effective on these terms alone. As well as transferring 12 elective orthopaedic beds to a different department we were able to perform an estimated 75 extra lower limb arthroplasties in the 6 month period.

Treatment of complex proximal humeral fractures remains controversial. In situations where accurate fracture reduction and fixation cannot be obtained, arthroplasty may be the preferred surgical option. The traditional operation of hemiarthroplasty in these situations is technically challenging, and a good functional outcome is dependent on reduction and healing of the tuberosities. Reverse Shoulder Arthroplasty (RSA) has been suggested as an alternative, and we sought to analyse and compare functional outcomes following the two procedures.

Ten patients who underwent hemiarthroplasty for acute fracture of the proximal humerus between 1999 and 2003 were reviewed. All fractures were assessed intraoperatively for open reduction and internal fixation of the fracture, but deemed to be unsuitable for fixation. From 2003 our management in this clinical situation changed, and ten subsequent patients underwent reverse shoulder arthroplasty using the S.M.R. reverse shoulder prosthesis (Systema Multiplana Randell, Lima, Italy). Clinical and radiological follow up was carried out at a mean of 31 months (hemiarthroplasty patients) and 15 months (RSA patients) post operatively.

Subjectively seven of 10 patients in the reverse group and seven of 10 patients in the hemiarthroplasty group rated their outcome as ‘very good’ or ‘excellent’. The mean ASES scores were 65 (range 40–88) in the reverse group and 67 (26–100) in the hemiarthroplasty group. The mean Oxford shoulder score was 29 (15–56) in the reverse group and 22 (12–34) in the hemiarthroplasty group. The mean active forward elevation in the hemiarthroplasty group was 108° (range 50–180) and in the reverse group 115° (45–40), and active external rotation 49° (5–105) and 48° (10–90) respectively. Differences in outcome scores between the two groups were not statistic ally significant (p value> 0.05).

This study provides the first direct comparison between RSA and hemiarthroplasty for complex proximal humeral fractures. The expected functional gains with Reverse shoulder arthroplasty were not seen, suggesting its use as the primary treatment for acute fracture should remain guarded.

Aim To review 6 months of early discharge with a dedicated ‘Accelerated Discharge Team’ (A.T.T.) at our institution.

Patients and Methods The team consisted of four nurses and three physiotherapists. Patients undergoing hip or knee arthroplasty were assessed pre-operatively and post-operatively for admission to the care of the A.T.T. against fixed criteria. Patients were visited at home on the day of discharge and every day until released from the care of the team. 333 patients underwent lower limb arthroplasty during the study period of which 305 (91.6%) were admitted to the A.T.T.

Results The mean length of stay for primary knee replacements was 3.30 days. 73% (95% C.I. 64%–81%) of patients undergoing total knee arthroplasty went home by 3 days and 93% (95% C.I. 87%–97%) by 4 days. Results for hip arthroplasty were similar. Of the 305 patients, 12 (4%) were readmitted to hospital within 6 weeks of discharge. Almost 90% of patients responded to a satisfaction survey. 94.2 % of those responding indicated that they would use the A.T.T. scheme again.

Discussion In the year before implementing the A.T.T. the mean stay for primary hip and knee replacements was over 9 days. We reduced this to less than 3.5 days for over 90% of our patients during the study period. The total cost of the scheme was just under £100 000 for the 6 month period. We estimate that 2000 bed days were saved during the same period. This is cost effective on these terms alone. As well as transferring 12 elective orthopaedic beds to a different department we were able to perform an estimated 75 extra lower limb arthroplasty operations in the 6 month period.

The management of peri-prosthetic fracture following total hip arthroplasty is difficult, requiring expertise in both trauma and revision surgery. With rising numbers of patients in the population living with hip prostheses in situ, their frequency is increasing, and controversy remains over their ideal management. The objective of this study was to review all peri-prosthetic fractures at a single institution to identify injury and treatment patterns, and their associated clinical outcomes.

Fifty-four peri-prosthetic fractures in 50 patients were reviewed to determine the relative frequency of fracture types, complication rates, and clinical outcomes. Patient data were obtained through review of the clinical notes and individual patient follow up. Clinical outcomes were evaluated using the Oxford Hip Score (OHS) and Harris Hip Score (HHS).

The fractures were classified using the Vancouver system, the majority of which were type B 1 (20) or type B2 (10). The mean time to union for all fracture types was 4.6 months. A high non-union rate was seen amongst fractures fixed operatively. Fifteen percent of fractures went on to develop loosening following treatment, suggesting under-recognition at the time of injury. The average HHS was 73.1 and OHS 30.3 for all fracture types, at a mean follow up of 3.3 years. Of the 15 patients treated with revision surgery, the most common complication was dislocation (27%).

Treatment of patients with peri-prosthetic fractures requires recognition of the challenging nature of these injuries, their associated poor prognosis, and high complication rate.

Background: The main aim of this study was to compare the effectiveness of a brief intervention based on cognitive-behavioural principles (Solution Finding Approach – SFA) with the McKenzie approach (McK). A secondary aim was to determine if there were any clinical characteristics that distinguished patients who responded best to the McKenzie method.

Methods: Eligible patients who were referred by GPs to physiotherapy departments in the UK with neck or back pain were randomly allocated to McK (n= 161) or to SFA (n=154) and their outcome compared at 6 weeks, 6 and 12 months. In addition, putative predictors within the McKenzie group were compared using univariate analysis to examine the relationship between variables and outcomes. Significant variables were assessed using multiple logistic regression analyses.

Results: Both groups demonstrated modest improvements in outcomes. There were no statistically significant differences in outcomes, except 2 small but significant differences at 6 weeks. At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). The number of treatment successes in the McK group depended upon the definition used, but were limited. Less chronic back pain (rather than neck pain) in patients demonstrating centralisation responded best.

Conclusion: In the original RCT there were few differences between McK and SFA though modest improvements in both. In a secondary analysis of the results for the McK group there were few treatment successes according to our definition of success; these were most likely to occur in back pain patients with shorter duration symptom who demonstrated centralisation response.

Introduction: Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. We performed two separate studies:

1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion

Method: 500 orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty.

200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below Hb of 8g/dL. Mean transfusion threshold in surgeons was 8.3g/dL compared to 7.9g/dL for anaesthetists (p< 0.01). 97% of surgeons transfused two or more units compared to 78% anaesthetists (p< 0.01). This threshold Hb increased if patient was symptomatic (surgeons 9.3g/dL, anaesthetists 8.8g/dL, p< 0.05), or if known to have pre-existing ischaemic heart disease (surgeons 9.0g/dL, anaesthetists 9.2g/dL, p< 0.05).

A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: Haemoglobin level below 9g/dL is the most common ‘trigger’ for blood transfusion. Surgeons tend to be more aggressive in their attitude to transfusion. A fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.

Recently, the International Consensus Statement Group reported that mechanical prophylaxis with foot-pumps should be considered “Grade A” recommendation for prevention of deep-vein thrombosis after total hip replacement. Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent duplex ultrasound studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance.

846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novame-dix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone.

Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05).

In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance.

Introduction: Management of periprosthetic fractures following total hip arthroplasty (THA) represents a difficult clinical problem, requiring expertise in both trauma and revision surgery. Estimates of the prevalence of postoperative fracture range from 0.1% to 2.1%, and with rising numbers of patients in the population living with hip prostheses in situ there is evidence that their frequency is increasing. There remains a paucity of data on the functional outcome of these injuries, and the objective of this study was to analyse outcomes for revision THA following periprosthetic fracture, and compare these to elective revision surgery.

Methods: 233 patients (234 hips) undergoing revision THA for femoral fracture were identified from the New Zealand National Registry, and clinical outcomes were measured using Oxford Hip Scores (OHS) completed six months post operatively. A control group of 234 patients undergoing elective revision THA was selected and matched for age, sex, and time since index operation.

Results: Comparative analysis of the registry patients showed clinical outcomes were significantly worse following revision THA for fractured femur than in controls (mean OHS 28.6 vs 23.6, p=0.006), though this difference was not apparent in patients under the age of 65 years (mean OHS 26.1 vs 23.8, p =0.6). A higher mortality rate was found among fracture patients (17.1% versus 10.7 %, p=0.05), and a statistically significant higher number of periprosthetic fracture patients died within 6 months of their surgery in comparison to controls (7.3% versus 0.9%, p=0.003). A higher rate of re-revision was observed in the fracture group (7.7% versus 2.6%, p=0.02).

Conclusions: To our knowledge this study represents the largest comparative series of periprosthetic fractures in THA with functional outcome data yet reported. Management of patients with periprosthetic fractures requires recognition of the challenging nature of these injuries, their associated poor prognosis, and high complication rate.

Microfracture is a stem cell stimulation technique to promote the healing of full thickness articulate cartilage defects

Sixty-six patients have undergone microfracture for full thickness articulate cartilage defects over a five year period. All procedures were performed by one surgeon following the technique of Steadman. All patients were under 46, had an isolated chondral lesion, had a stable well aligned knee and were a minimum of one year post surgery.

Patients were evaluated with a preoperative and follow up IKDC score, WOMAC score, KOOS Score, Tegner activity level and SF 36, VAS pain scores and overall knee function score. Failure was determined by the need for a secondary chondral procedure.

Nine patients failed. Thus the overall success rate was 86%. The failure rate was higher with larger lesions.

There was a significant improvement in IKDC score, WOMAC score, KOOS Score, Tegner activity level and SF 36, VAS pain scores and overall knee function score.

Microfracture has a good success rate in the short to medium term with isolated full thickness articular cartilage lesions in the stable well aligned knee.

The purpose of this study was to characterise accurately, the extent and geometry, and produce representative rigid resin models of full thickness articular cartilage lesions of various types, shapes and sizes on the articular surface of pig patellae.

Ten adult pig patellae and three adult Ox patellae were obtained and cleared of adhering tissue. Full thickness lesions were induced from oval shaped to “U” shaped scarifications by careful use of a hand held bur, and the geometry noted by taking appropriate dimensions with a Vernier cailper in the horizontal and vertical planes, and plan view photographs. MRI images using fat-suppressed weighted 1.5 mm thick slices scans in the horizontal plane, were produced in DICOM format for conversion to SLE files used in the reconstruction in the computer. The patellae were then held in a stone plaster mix to produce a male mould of the articular surface. The computer images were generated and the physical dimensions taken with the Vernier calliper were recorded from the reconstructed image in the computer using graphics software. The computer data was used to produce a rigid full scale model of the articular surface in resin using laser stereolithography which is using in the rapid prototyping industry. The resin models were matched with the male plaster moulds to confirm an accurate match of the 3-dimensional shape of the computer generated in all the types of lesions we produced. It is proposed to use the rigid models to produce sterile templates that could be used by surgeons to fashion an area around a lesion using a suitable reamer/bur using a predetermined criteria of cartilage thickness (say 2 mm), and the same geometrical data would be used to produce a suitable semi rigid scaffold shaped to the lesion. Our study has shown that very accurate 3 dimensional data can be quickly processed from MRI images to produce, using current rapid prototyping techniques, templates and implants to fit lesions accurately in the patella. There is no reason why this technology could not be applied to any joint surface that can be accessed by MRI.

Bleeding from cancellous bone causes lamination within bone cement and at its prosthetic interfaces, and weakens the fixation of joint replacements. We examined the effects of anaesthesia and blood pressure on bleeding in human cancellous bone, and investigated the local response to freezing saline, 1:200,000 adrenaline and hydrogen peroxide. Spinal anaesthesia reduced cancellous bleeding by an average of 44%, local freezing saline by 24%. Saline at room temperature, adrenaline solution and hydrogen peroxide each reduced it by 14%. The effects of spinal anaesthesia and of freezing saline were additive: used together they reduced bleeding by 56%. The reduction of blood contamination of cement and its interfaces should contribute to better prosthetic fixation.

Since 1974, we have made a prospective study in Bristol of the results of unicompartmental knee replacement using the St Georg sledge prosthesis. A total of 115 knees in 100 patients have been followed up for 2 to 12 years (mean, 4 years 9 months). Results have assessed both by the Bristol knee score and by survivorship studies on the total series of 138 knees. Results were excellent or good in 86% and fair or poor in 14%. The survivorship study (based on a definition of failure which included significant pain or a dissatisfied patient or the need for revision) showed a cumulative success rate of 76.4% at six years, with no further failures after that time. Seven knees have been revised, in most cases for deterioration of the contralateral compartment. The operation is recommended as a satisfactory and durable form of treatment for osteoarthritis affecting a single tibiofemoral compartment.