Intrapelvic migration of the acetabular component of a total hip replacement, with severe acetabular destruction making reconstruction impossible, is very rare. We present a patient in whom the component was removed using a laparotomy and a transperitoneal approach with subsequent salvage using a saddle prosthesis and a total femoral replacement.

Introduction: The aims of this study were to determine whether patients were transfused appropriately, after a Unilateral Cemented Primary Total Knee Replacement (TKR), and whether it would be cost effective to use autologous transfusion drains compared with standard group & save and cross match protocols.

Method: Retrospective study of the pre- and postoperative day 1 haemoglobin values of all patients who underwent unilateral primary cemented TKR between November 2004 – November 2005 at the Kent & Sussex Hospital, Tunbridge Wells. Haemoglobin data and length of stay was obtained from computerised records & transfusion data from the blood transfusion department.

Results: 150 patients were assessed: 97 (65%) female and 53 (35%) male. 20 (14.6%) patients required blood transfusion. The mean preoperative haemoglobin for non-transfused and transfused patient’s was 13.7 and 12.5g/dl respectively (P = 0.0029). The mean postoperative haemoglobin for non-transfused and transfused patient’s was 11.1 and 9.27g/dl respectively (P< 0.001). The mean blood loss for non-transfused and transfused patient’s was 2.64 and 3.26g/dl respectively (P< 0.001). There was no significant correlation between length of stay and either preoperative haemoglobin or blood loss after surgery; Spearman’s correlation coefficient was 0.0222 and 0.0036 respectively. The cost of a standard group & save and cross match, plus the 56 required units of blood in this study was £15,443.60. The theoretical cost of using a CellTrans Autologous Transfusion System on these 150 patients would be £14,355.00, a saving of only £1,088.60. However, by only using the autologous drains on patients with a preoperative haemoglobin ≤ 12.5g/dl, this saving could be increased to £4,131.20 per annum.

Conclusion: Using autologous transfusion drains on patients with a preoperative haemoglobin ≤ 12.5g/dl would save over £4,000 per annum at Maidstone & Tunbridge Wells Hospital Trust. There is no correlation between length of stay in hospital and either preoperative haemoglobin or blood loss after surgery. Patients transfused had significantly lower pre- and postoperative haemoglobins.

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches.

Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS.

AIM: To find out the affect of surgical approach on oxford hip score.

Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem AND were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS.

Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively.

CONCLUSION: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients.

We report the clinical and radiographic outcome of a consecutive series of 219 hydroxyapatite-coated total knee replacements with a follow-up of 5 to 8 years.

Patients who fulfilled the entry criteria were included in a prospective study from early 1997 to late 1999. Regular clinical & functional assessment was subsequently performed using the Knee Society Score, WOMAC & SF-12 self-assessment questionnaires. Analysis of fluoroscopically controlled radiographs was performed using the American Knee Society Score.

All living patients (186 knees) were followed-up. Exhaustive efforts were made to ensure that no patient was lost to follow-up. 28 patients (30 knees) were deceased. There have been 3 revisions.

The mean pre-operative Knee Score of 43.8 increased to 77.1 and the mean pre-operative Function Score of 20.3 increased to 63.4 at 5 years. The WOMAC scores also showed marked improvement from pre-operative status after 5 years minimum follow-up: pain 250 pre-op to 157, stiffness 115 pre-op to 56 and function 910 pre-op to 588.

There was no radiographic evidence of loosening or migration. The average American Knee Society Score for each component was 4. Small gaps between the bone-implant interface were observed to heal over the first year. A separate phenomenon of focal osteopenia is also described in a small number of well-fixed femoral components (12 of 219).

To date, 3 prostheses have been revised, 2 due to deep infection and 1 due to tibial tray subsidence. A survivor-ship of 98.6% has been achieved at 8 years.

We believe this to be the first medium term study for the Duracon HA coated knee arthroplasty system, showing excellent clinical and radiographic outcome, with 100% follow-up at 5 to 8 years.

To evaluate the performance of this institution in its delivery of care to elderly patients with a hip fracture over an 11-year period and to establish recommendations to improve practice.

Regular prospective audits of a cohort of 50 patients have been undertaken between 1990 and 2000. A larger and more comprehensive retrospective audit of 100 patients was performed in 2001. Goals were set regarding time to admission, time to surgery and to discharge in close accordance with the best practice guidelines devised by the Royal College of Physicians in 1989.

There has been an alarming decline in standards in key areas.

Time from A& E to admission: at best 78% of patients within 3 hours, 4% in 2001.

Current practice is less than ideal. Clinical governance involves a dual responsibility – of the clinician to maintain high standards and of the management to provide adequate resources. Both need addressing to reverse the current trend.

The success of uncemented arthroplasty depends on the achievement and maintenance of implant stability. Despite the use of modern instrumentation to obtain an accurate implant fit during total knee replacement, small gaps often remain visible at the bone-prosthesis interface on high quality fluroscopically-assisted radiographs. Although the clinical significance of these gaps is unclear, their presence delays bony fixation of the implant.

In uncemented total hip arthroplasty, hydroxyapatite costing has been used to enhance early stability of the implant: bony apposition has been shown to occur rapidly even in the presence of a small gap between the implant and the bone. In addition, recent RSA (Radio-stereo-photogrammateric analysis) studies have shown reduced micromotion and enhanced implant stability with hydroxyapatite coating of both hip and knee prostheses.

The following study was designed to observe and investigate the phenomenon of ‘gap-healing’ around hydroxyapatite coated uncemented total knee prostheses.

Over a 15-month period a hydroxyapatite coated uncemented total knee prosthesis was implanted in 99 patients undergoing 108 primary knee arthroplasties. The patients were prospectively reviewed at regular intervals with an average follow up of 18 months and a minimum of 12 months. The implant-bone interface was evaluated by obtaining serial fluroscopically-assisted radiographs.

On the immediate postoperative radiographs, small gaps between the implant and bone were seen in most knee. These gaps were visible on average in 2.16 AKS (American Knee Society)zones per knee. Most of the gaps were seen in Femoral zones 2,3,5 and Tibial zones 1 & 4. The majority of the gaps were under 1mm depth. Gaps> 2mm were seen only in 6 patients. Healing of the gaps was first seen at 3 months postoperatively, the average number of zones involved per knee dropping to 1.54. There was good evidence of ‘gap healing’ occurring at all the bone-implant interface zones. At the end of the first postoperative year, only 0.8 zones per knee were involved.2mm gaps remained visible in 3 patients.

In animal experiments, hydroxyapatitie coated porous surfaces have shown an increased the rate of bone ingrowth for as many as 52 weeks after implantation. In our study, progressive bone ingrowth and gap-healing has been observed beyond this period, the average involved zones on 2 –year radiographs being 0.4 per knee.

During the study period, the American knee score improved from 39.52 preoperatively to 89.97 at 1 year postoperatively. No relation was found between the clinical scores and the presence or absence of gaps on follow-up radiographs.

This study demonstrates the phenomenon of ‘gap-healing’ following uncemented hydroxyapatitie coated primary total knee arthroplasty in an unselected group of patients. Gaps under 1 mm at the implant –bone interface heal readily. Healing of gaps> 2mm is less predictable.

We report a prospective study of 198 cases of subcapital fracture of the femur treated by closed reduction and fixation with a sliding compression screw-plate. This was done without regard to the patient's age or the Garden stage of the fracture. Early weight-bearing was encouraged. Of the displaced fractures 23% failed in the first year because of non-union or infection. Of the fractures which united 27% had developed avascular necrosis after three years. Despite this we believe that the sliding compression screw-plate, of proven value in the treatment of intertrochanteric fractures, is also useful for the fixation of subcapital fractures.