Periprosthetic femoral fracture (PFF) incidence following hip replacement surgery continues to rise. There is a national drive to centralise PFF treatment within specialist centres to improve clinical outcomes and cost-effectiveness. The financial implications of treating PFFs must be analysed to guide allocation of funding.

Data were collected for 129 PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by the Patient Level Information and Costing Systems (PLICS) team. Primary outcomes were cost, revenue and margin for each PFF. Additional data were collected on length of stay (LOS), critical care requirements and clinical outcomes. Statistical comparisons were made between treatment type (fixation vs revision). Significance was set to p<0.05.

Across the entire cohort, total cost was £2,389,901, total revenue was £1,695,435 and total loss was £694,481. Highest costs were ward stay (£714,591), theatre utilisation (£382,625), and overheads (£249,110). Median cost was £15,863 (IQR, £11,092-£22,221), median revenue was £11,305 (IQR, £7,147-£15,222) and median loss was £3,795 (IQR, £605-£8687). Median LOS was 21 days (IQR 13–34) and 28.7% patients required critical care admission.

Ninety-six patients were treated operatively with either fixation (n=53) or revision (n=43). Median operating time was lower for fixation versus revision (132 [IQR, 115–185] vs 201 [IQR, 159–229] minutes, p=0.001). Median cost (£17,455 [IQR, £13,095-£22,824] vs £17,399 [£13,394-£23,404]) and median loss (£5,774 [IQR, £2,092-£10,472] vs £3,860 [IQR, £96-£7,601]) were similar for fixation and revision (p=0.99 and p=0.18, respectively). Median revenue was greater for revision versus fixation (£13,925 [IQR, £11,294-£17,037] vs £12,160 [IQR, £8,486-£14,390], p=0.02). There was no difference in LOS (21 [13–34] vs 21 [14–30] days, p=0.94), critical care requirements (20 [37.7%] vs 11 [25.6%], p=0.30), reoperations (3 [5.7%] vs 6 [14.0%], p=0.29], local complications (8 [15.1%) vs 12 [27.9%], p=0.20) or systemic complications (11 [20.8%] vs 11 [25.6%], p=0.75) between fixation and revision.

PFF treatment costs are high with inadequate reimbursement through tariff. Work is needed to address this disparity and reduce costs associated with LOS, theatre utilisation and implants. Treatment cost should not be used when deciding between fixation and revision surgery.

In an initial randomised controlled trial (RCT) we segregated 180 patients to one of two knee positions following total knee replacement (TKR): six hours of knee flexion using either a jig or knee extension. Outcome measures included post-operative blood loss, fall in haemoglobin, blood transfusion requirements, knee range of movement, limb swelling and functional scores. A second RCT consisted of 420 TKR patients randomised to one of three post-operative knee positions: flexion for three or six hours post-operatively, or knee extension.

Positioning of the knee in flexion for six hours immediately after surgery significantly reduced blood loss (p = 0.002). There were no significant differences in post-operative range of movement, swelling, pain or outcome scores between the various knee positions in either study. Post-operative knee flexion may offer a simple and cost-effective way to reduce blood loss and transfusion requirements following TKR.

We also report a cautionary note regarding the potential risks of prolonged knee flexion for more than six hours observed during clinical practice in the intervening period between the two trials, with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy at their three-month review.

Cite this article: Bone Joint J 2014;96-B:201–9.

With greater numbers of younger patients undergoing total hip replacement (THR), the effect of patient age on the diameter of the femoral canal may become more relevant. This study aimed to investigate the relationship between the diameter of the diaphysis of the femoral canal with increasing age in a large number of patients who underwent THR. A total of 1685 patients scheduled for THR had their femoral dimensions recorded from calibrated radiographs. There were 736 males and 949 females with mean ages of 67.1 years (34 to 92) and 70.2 years (29 to 92), respectively. The mean diameter of the femoral canal was 13.3 mm (8.0 to 23.0) for males and 12.7 mm (6.0 to 26.0) for females. There was a poor correlation between age and the diameter of the canal in males (r = 0.071, p = 0.05) but a stronger correlation in females (r = 0.31, p < 0.001).

The diameter of the femoral canal diameter of a female patient undergoing THR could be predicted to increase by 3.2 mm between the ages of 40 and 80 years, in contrast a male would be expected to experience only a 0.6 mm increase during the same period. This increase in the diameter of the canal with age might affect the long-term survival of the femoral component in female patients.

Cite this article: Bone Joint J 2013;95-B:339–42.

Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion. In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA. Patients who were undergoing TKA were prospectively randomised into two groups - one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS). The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3months and 1year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation. There was a significant gain in flexion after wound closure in the PCS group (p=0.022), however there was no significant difference at 3months or 1year post-operatively. Absolute values of extension (p=0.008) and flexion (p=0.001) 3months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3months (p=0.0002) and 1year (p=0.005). There were no significant difference in the rate of complications. Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA.

Aims

Hip fractures pose a significant burden on the healthcare system. Hyperglycaemia and a state of Type 2 diabetes exists post operatively. Being normoglycaemic has well documented benefits. Pre operative carbohydrate loading has been shown to have two good effects. It decrease hyperglycaemia post operatively and allows the patient to undergo less strict fasting protocols. Insulin resistance to date has not been examined in these patients and this was determined using a validated formula (HOMA/IR).

Fracture neck of femur (NOF) is a significant morbidity in the elderly patient and a significant burden on the healthcare system. Surgery induces a stress response resulting in hyperglycaemia, insulin resistance, and glucose intolerance (Diabetic triad). Furthermore, fasting pre operatively establishes a catabolic state. This diabetic state can last up to 3 weeks following surgery and therefore could be associated with the morbidity of diabetes.

Introduction: Surgery may cause a metabolic response leading to a diabetic state characterised by hyperglycaemia, insulin resistance and glucose intolerance. Metabolic stress may be worsened by the practice of Nulla Per Os (NPO).

Hip fracture patients are often subjected to fasting for extended periods. We hypothesise that a pre operative high carbohydrate drink permitted prior to surgery would mitigate the post operative diabetic state.

Methods: Ethical and Anaesthetic approval were obtained. 40 patients with hip fractures were enrolled over 4 months at Mayo General Hospital and were randomized to two groups. 20 were enrolled into Group A: control traditional NPO and Group B: Carbohydrate group. Data collection: Glucose and insulin serum levels were recorded regularly at: preadmission, post op and post op days 1 & 5; and weeks 2,3 & 6. Drink protocol: 800mls before midnight and 400mls on the morning of surgery. Exclusion criteria included diabetics and pregnancy. Hospital length of stay (HLOS), morbidity and readmissions were noted.

Result: Average age Group A: X Group B:Y. Hyperglycaemia post operatively noted in 70% of Group A vs 30% in Group B. Hyperinsulinaemia postoperatively noted in 75% of Group A vs 28% Group B. Group A and B had similar HLOS and post operative morbidity. However, we noted a higher readmission rate 45% in Group A.

Conclusion: Preoperative Carbohydrate loading significantly decreases post operative hyperglycemia and hyper insulinamia. This may show that converting a patient from fasted to a fed state prior to the insult of surgery prevents the patient entering a diabetic state and avoiding morbidity associated with same.

Introduction: Range of motion (ROM) is an important measure of the success of knee Arthroplasty. The extent to which pain relief contributes to improvements in knee ROM in total knee Arthroplasty (TKA) patients is unknown. This prospective study assessed the separate effects of pain abolition and surgery on ROM in a group of 141-osteoathritic patient’s undergoing TKA. Pain had a significant inhibitory effect on knee ROM. Improvements in ROM following TKA may be primarily due to pain relief.

Methods: 141 randomly selected patients underwent LCS total knee arthroplasty (De Puy). A single surgeon performed all operations, using an identical surgical technique. Passive flexion and extension were measured when awake, under anaesthesia, and post-operatively under anaesthesia.

Paired t-tests were used to test for significant differences between the measurements. Independent samples t-tests were used to test for significant differences between the changes in flexion, extension and ROM between the time points tested.

Results:

When awake the mean flexion was 116.8°, extension 3.8°, and ROM 113.0°

Knee flexion (p < 0.0001) and range of motion (p < 0.0001) were significantly greater and knee extension (p < 0.0001) was significantly reduced following anaesthesia only. A further significant increase in knee flexion (p < 0.0001) and range of motion (p = 0.00014) was observed post –operatively under anaesthetic. However knee extension did not significantly increase further (p = 0.29). The average improvement in range of motion once anaesthetised was 16.4° (SD = 13.1°) with the majority of this improvement due to an increase of flexion (average increase of 13.4° (SD = 11.9°) rather than an increase in extension (average increase of 3.0° (SD = 4.2°).

The combined effect of surgery and anaesthetic was 20.5° (SD = 12.3°), with the majority of this improvement due to an increase of flexion (average increase of 17° (SD = 8.5°) rather than an increase in extension (average increase of 3.6° (SD = 6.0°).

Discussion: Pain abolition resulted in a mean increase of 16.4° in the range of motion, and both TKA combined with pain abolition further increased significantly the range of motion to a mean of 20.5°. This study suggests that improvements in ROM following total knee arthroplasty are primarily due to reduction in the symptoms of pain and that other factors such as surgical technique and prosthesis design can further increase ROM.

Future studies should record the measurements of passive flexion, extension and range of motion in the anaesthetised patient, as this will allow objective assessment of changes in range of movement.

Introduction: During the postoperative follow up of patients who underwent primary total hip replacement, it was observed that the haemoglobin concentration had dropped more than expected when compared to the intra and postoperative (drain) loss. This study was carried out to ascertain whether this drop in haemoglobin reflects a real blood loss or is due to hemodilution secondary to intravenous fluids, or both. Also to establish the average amount of blood loss responsible for the drop of one gm of haemoglobin concentration, in order to confirm or alter the old belief that every 500ml of blood loss is responsible for 1 gm drop in Hb concentration.

Method: A prospective study was carried out to include 20 patients undergoing primary total hip replacement due to osteoarthritis in the period, March to November 2006. 2 drains were used, one was deep and the other was superficial. 7 samples of haemoglobin were taken in every case. The first sample preoperatively, the second postoperatively in the recovery room, the third and forth samples taken 6 hours postoperatively from the patient and the deep drain. The fifth and sixth samples from the patient and the deep drain 24 hours postoperatively. And the last sample from the patient 5 days postoperatively. Also the IV Fluids given were recorded in the first 24 hours.

Results:

The Hb concentration in the deep drain was gradually decreasing over the first 24 hours after the operation when compared to the patient’s Hb which means that the total volume of the drain loss doesn’t mean an equal volume of blood loss.

Total hip arthroplasty has improved the quality of life for many patients with osteoarthritis. Infection is a serious complication, difficult to treat and often requires removal of the prosthesis to eradicate the infection.

An analysis of the surgical management, risk factors, complications and outcome of infected total hip replacements. Thirty one consecutive patients underwent revision hip arthroplasty for infection between 1997 and 2003. Risk factors, co-morbidity, clinical presentation, biochemical profiles, microbiology, management and radiology were recorded. Outcome and complications following surgery are reviewed. Classification of infection after total hip arthroplasty was based on their clinical presentation—early postoperative, late chronic, or acute hematogenous infection, and positive intraoperative cultures.

All patients underwent resection arthroplasty, 26 had a two-stage revision, 1 had a three stage, 4 did not have a re-implantation. Staph Aureus was the most common organism identified. 16 patients were classified as late chronic insidious, 8 early post operative infection, 6 acute haematogenous and 1 occult intraoperative. Average total blood loss was 5 litres, average replacement was 7 units. 1 patient had a persistent infection. 3 underwent further surgery for dislocation, stem perforation or fracture. 5 patients had a persistent limp.

In infected revisions the bone stock is usually adequate, the soft tissues are very poor. Bivalving the femur allows for optimal cement removal. Blood loss can be significant with average replacement of 7 units. Meticulous removal of infected components, cement and tissue is essential for good long-term results.

Introduction: Wear, and the resultant loosening and revision, of Total Hip Replacements (THRs) remains the limiting factor in the long term success of the prosthesis. Over 1 million Total Hip Replacements (THRs) are implanted each year, of which about 15% are revisions, most of which are a consequence of loosening of either femoral or acetabular components. This is frequently caused by either the mechanical (Wroblewski, 1986) or biological (Besong et al, 1997) response to the wear of ultra-high molecular weight polyethylene (UHMWPE) acetabular component.

In a previous study Bennett (2002, 2000) has demonstrated that the walking patterns of THR patients 5 years post operation directly correlated with the wear of the acetabular component, as measured radiographically. The present study considers THR patients 10 years post-operatively, ensuring more accurate wear measurements and more meaningful outcome measures.

Materials and Methods: Gait Analysis was performed on a number of THR patients following routine review using a Vicon 370 data capture system and a lower body marker set. This data was processed using Polygon software and joint angles were derived for the hip in the sagittal, coronal and transverse planes. A computer simulation was used to determine the path which each of 20 points on the prosthetic femoral head traces on the acetabulum during walking.

Results: It was found that patients exhibited different patterns of movement ranging from liner to multi-directional. Normal subjects have previously been found to exhibit multi-directional movement. Patients with mult-directional movement showed evidence of greater wear (Bennett et al., 2000).

Discussion and conclusion: Linear movement causes orientation hardening and wear resistance while multi-directional movement cause increased shear and greater wear rates. These differences in movement loci have a significant influence on UHMWPE wear rate and the long term survival of the implant.

In 1993 a specialist limb length discrepancy and deformity clinic was established at Our Lady’s Hospital for Sick Children. Since then, the senior author has performed 193 lower limb lengthenings. Of these, there were 50 paediatric cases who had 74 segments lengthened using the Ilizarov method of distraction osteogenesis. A retrospective study of data and radiographic review of these children was performed. In particular, the grade of severity of deformity and complications encountered whilst lengthening were documented.

Complications were defined as any unwanted event and graded as minor or major with the major complications being further classed as serious or severe. Each patients deformity was classified using the Dahl Deformity Severity Scale which grades deformity according to percentage length discrepancy.

There were 26 females and 24 males in the study population, their average age being 13.1 years (range 2.8–18 years). 65% of the lengthenings had a congenital aetiology for the deformity. The mean hospital stay was 7 days and the average length achieved was 4.9cm. There were 79 minor complications and 48 major complications. The overall complication rate (total complications divided by the number of segments lengthened) was 1.74%.

This study shows how the Deformity Severity Scale may be used as a prognostic indicator to identify limb deformity at high risk of lengthening complication. It may also be used to determine the relative complication risk for each patient according to his or her percentage limb length discrepancy.