Salvage Total Hip Arthroplasty (THA) presents a viable solution following failed treatment of a hip fracture. Several studies have suggested higher complication rate including high dislocation rate associated with salvage THA. The present study evaluates the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of a hip fracture and comparison made to Primary THA in osteoarthritis (OA). Between 1992 and 2007, 53 patients with a mean age of seventy years were treated with THA after the failed treatment of a hip fracture under the care of a single surgeon. The indication for conversion arthroplasty was Avascular necrosis head – 24(45.3%), screw cut out – 6 (11.3%), non-union – 2(3.8%), Displaced fracture – 2(3.8%), Secondary OA – 19 (35.8%). The implants retrieved were Cannulated screws – 3, Sliding plate and screw – 46, Spline plate – 2, Smith Petersons nail – 1, Martin Plate – 1. This group of patients were matched for age, sex, side, and ASA grading with a group of 59 patients who underwent THA for primary osteoarthritis (THA-OA group). Posterior approach was used in all cases. Four patients (7.5%) required grafting of cup and 21 patients (39.6%) required soft tissue release. The average blood loss was 555 ml, mean duration of surgery was 85.5 min, average inpatient stay was 6.7 days. Cemented THA was used in 43 patients and Cementless THA in 10 patients. At one year follow up there were no dislocations, one patient had an undisplaced femoral fracture treated in Spica. Three patients had broken screws; one patient with shortening > 1 inch. There was one revision for deep infection. The mean Harris Hip Score (HHS) improved from 28.4 to 82.5 at one year, while the Oxford Hip score (OHS) improved from 50.9 to 21.9 (Old system). When the scores were compared to the THA-OA group there was no difference in the oxford hip scores and the the mean one year HHS in the THA-OA group was slightly higher than the group with salvage THA, but the difference was not statistically significant. Hip arthroplasty is an effective salvage procedure in patients with prior surgery for hip fracture. Most patients have good pain relief and functional improvement. Despite the operative challenges, remarkably few serious orthopaedic complications were associated with this procedure in the present study.

A prospective study of 276 TKA's performed in patients with valgus knee deformity ≥ 10° using a Modified Surgical Technique.

Currently, the optimal treatment of pipkin fractures remains controversial. To rovide guidance on the management of these challenging injuries, we systematically viewed the available literature on outcomes following presentation with pipkin fracture dislocations and meta analysis was applied where applicable.

Material and Methods: Electronic databases were searched for studies on “Pipkin fractures”. Thompson & Epstein scale used as primary outcome measure and Merle’d Aubgine score, AVN, Nerve injuries, Heterotrophic ossification used as secondary outcome measures.

Results: This metaanalysis included 242 cases from 13 studies. Mean age of patients is 41.2 (sex ratio 7:3 male to female). Motor vehicle accidents contributes to 93% of cases, followed by fall from height in 6% cases. Patients were divided in to two groups, one with hip reduction with in 6 hours and second group more than 6 hours. ‘P’ value calculated using CMA software has shown no statistical advantage of reducing hip in less than six hours (p – 0.87). Majority of Type I cases treated by excision, type II cases were treated by ORIF. Type III cases predominantly treated by arthroplasty, where as type IV cases mainly treated by open reduction and internal fixation. Thompson & Epstein results were excellent in 13% of cases, 47% good, 16% fair to satisfactory and 24 % cases reported poor results. Incidence of good results descended from Type I to Type IV, where as incidence of poor results increased. Meta analysis of TE results and surgical approach has not shown any advantage of anterior or posterior approach in producing better TE outcomes. Similarly early time to reduction or surgery also failed to show any statistical advantage over delayed reduction or surgery. Analysis of the outcomes treated by non operative and operative methods in type I cases has shown operative methods producing less favourable outcomes in type I fractures with a p value of poor outcomes 0.018, showing advantage of non operative methods in type I fractures.

In type II, III & IV cases, no statistically significant advantage is noticed in this respect. Overall incidence of AVN is 11%, highest incidence is reported in type III fractures.Highest incidence of Heterotopic ossification is reported in anterior or anterolateral approaches. Incidence of nerve injury in Pipkin fractures reported as 13%.

Conclusions: Pipkin fracture is a high energy complex trauma resulting in significant morbidity.

Incidence of poor results increases from type I to type IV cases. Statistically no significant difference is added on to anterior or posterior approaches or timing of reduction within or after six hours in the management of these fractures based on TE results. This meta analysis proving type of fracture is the most important prognostic factor influencing the outcome.

The angle of inclination of the acetabular component in total hip replacement is a recognised contributing factor in dislocation and early wear. During non-navigated surgery, insertion of the acetabular component has traditionally been performed at an angle of 45° relative to the sagittal plane as judged by the surgeon’s eye, the operative inclination. Typically, the method used to assess inclination is the measurement made on the postoperative anteroposterior radiograph, the radiological inclination.

The aim of this study was to measure the intra-operative angle of inclination of the acetabular component on 60 consecutive patients in the lateral decubitus position when using a posterior approach during total hip replacement. This was achieved by taking intra-operative photographs of the acetabular inserter, representing the acetabular axis, and a horizontal reference. The results were compared with the post-operative radiological inclination.

The mean post-operative radiological inclination was 13° greater than the photographed operative inclination, which was unexpectedly high. It appears that in the lateral decubitus position with a posterior approach, the uppermost hemipelvis adducts, thus reducing the apparent operative inclination. Surgeons using the posterior approach in lateral decubitus need to aim for a lower operative inclination than when operating with the patient supine in order to achieve an acceptable radiological inclination.

Aims: Hypokalemia is a common electrolyte imbalance with signficent effects. The aim of our study is to identify incidence, causes and prognostic implications of postoperative hypokalemia in elderly patients operated for fracture neck of femur.

Methods and material: Retrospective study, of 404 consecutive fracture neck of femur patients who were operated in our hospital between October 2001 and July 2003. Patients identified with postoperative hypo-kalemia the medical notes, fluid charts and anaesthetic notes were analysed for age, preoperative morbidities, medications, mechanism and type of injury, waiting time for operation, pre, peri and postoperative fluid management, type of anaesthesia, operative time, hospital stay and mortality.

Results: Out of the 404 patients, 54(13.3%) were hypokalemic (K< 3.5mmol/l) postoperatively. Of the 54 patients 16 (29.6%)had preoperative hypokalemia.

Among the hypokalemic group the mean preopera-tive potassium was 3.69mmol/l and the mean postoperative potassium was 3.19mmol/l. The t-test showed a statistically significant difference between mean pre and postoperative potassium levels (P< 0.0001). High association was found with hypokalemia and post-operative dextrose infusion (38%). 50% of patients on diuretics developed hypokalemia post operatively. Interestingly, only 18% of these were hypokalemic pre operatively.

In patients with multiple medical problems, like diabetes, hypertension and CVA, high incidence of hypokalemia was found. (38% had 2 or more medical problems).

No significance in the mortality rate was found in fracture neck of femur patients with and without postoperative hypokalemia (40% vs. 39% at 3yrs).

Conclusion: There is significant risk of hypokalemia following orthopaedic surgery, especially in the elderly. This avoidable condition, which has serious consequences, should be dealt with care in the orthopaedic units. Fluid infusion regimes and should be formulated and medications reviewed to prevent conditions like hypokalemia.