Introduction

The removal of a well fixed cement mantle for revision of a total hip replacement (THR) can be technically challenging and carries significant risks. Therefore, a cement-in-cement revision of the femoral component is an attractive option.

The Exeter Short Revision Stem (SRS) is a 125 mm polished taper stem with 44 mm offset specifically designed for cement-in-cement revisions. Only small series using this implant have been reported.

Introduction: Elective joint replacement patients routinely require transfusion following surgery. Haemoglobin must remain within red blood cells in order to be functional. The process of surgery and collection in the reinfusion drain may disrupt cell membranes resulting in non functional haemoglobin. The filtration and collection process does not eliminate free haemoglobin. This results in intracellular and free haemoglobin being transfused into patients giving false functional haemoglobin levels.

Aim: To determine the proportion of intracellular haemoglobin in autologous blood transfusion drain following joint replacement.

Research Methodology: Research ethical approval was obtained prior to conducting this study. 20 consecutive patients undergoing elective total hip replacement (THR) and 20 consecutive patients undergoing elective knee replacement (TKR) from April 08–July 08 were consented to participate in this study. A standard full blood count sample of 3 mls was taken from the rein-fused blood. Each sample had the total haemoglobin (THb) concentration determined (i.e. free and intra-cellular) from the blood in the specimen tube. The sample was then centrifuged, and the THb of the supernatant was determined. This determined the concentation of ‘free’ haemoglobin. From these two respective values, the proportion of haemolysed haemoglobin was determined from each sample.

Results: There were a total of 35 participants of which 20 were TKR and 15 were THR. The average THb concentration for the THR and TKR were 7.7g/dl and 10.3g/dl respectively. The proportion of haemolysed Hb was 1.46% and 0% respectively. The THb and proportion of haemolysed Hb for all 35 patients were 8.76g/dl and 0.63%.

Conclusion: Autologous blood transfusion is not only safe and economical but remains an effective procedure with a negligible proportion of haemolysis

Our study evaluated the reliability of the Crowe and Hartofilakidis classification systems for developmental dysplasia of the hip in adults. The anteroposterior radiographs of the pelvis of 145 patients with 209 osteoarthritic hips were examined twice by three experienced hip surgeons from three European countries and the abnormal hips were rated using both classifications. The inter- and intra-observer agreement was calculated.

Interobserver reliability was evaluated using weighted and unweighted kappa coefficients and for the Crowe classification, among the three pairs there was a minimum kappa coefficient with linear weighting of 0.90 for observers A and C and a maximum kappa coefficient of 0.92 for observers B and C. For the Hartofilakidis classification, the minimum kappa value was 0.85 for observers A and B, and the maximum value was 0.93 for observers B and C. With regard to intra-observer reliability, the kappa coefficients with linear weighting between the two evaluations of the same observer ranged between 0.86 and 0.95 for the Crowe classification and between 0.80 and 0.93 for the Hartofilakidis classification.

The reliability of both systems was substantial to almost perfect both for serial measurements by individual readers and between different readers, although the information offered was dissimilar.

To determine socket survivorship in DDH based on the severity of hip dysplasia, we carried out a retrospective study of 283 cemented total hip replacements carried out at Wrightington. The hips were classified according to the Crowe and Hartofilakidis classifications. Revision was used as the end point for prosthetic survivorship. The results were analysed statistically using SPSS for Windows

The mean age at time of surgery was 42.6 years with a mean follow-up of 15.7 years. The acetabulum was grafted in 46 cases. The commonest cause for revision was aseptic loosening of the acetabular component (88.3%). 254 procedures were carried out through a transtrochanteric approach with a direct lateral approach used for the remaining mildly dysplastic hips. At 10 years 5.3% of dysplastic, 14.8% of low dislocation and 51.1 % of high dislocation hips were revised.. At 10years 6% of Crowe Type1, 8.5% of Type2, 25.5% of Type3 and 39.2% of Type4 hips were revised. At 20 years 24% of dysplastic, 45% of low dislocation and 88% of high dislocation hips were revised. At 20years 27.3% of Crowe Type1, 29.3% of Type2, 63.3% of Type3 and 84.4% of Type4 hips were revised. The 20 year survival of patients less than 50 years of age at the time of surgery was 61% as compared to 92% survival in patients more than 50 years of age. The mean age of patients in the revised group was 35 years as compared to 45 years in the non-revised group.

Conclusion: This study demonstrates satisfactory results in dysplastic hips following cemented total hip replacements. With increasing severity of hip dysplasia there is a higher rate of premature failure of the acetabular component. There is adverse correlation between age and survival of the acetabular component. There is a dramatic increase in cup failure between 10 and 20 years.

In 1999 a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Association for Surgery of the Knee (BASK) to provide a basis for regional and national auditable standards: we have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.

A direct comparison of data held on the North West Hip Arthroplasty Register for 2001/2002 and BASK/BOA guidelines was performed. 86 surgeons from 26 hospitals were included in the study. A mean of 93.3% of operations were performed in the surgeon’s usual theatre. All of these theatres had vertical laminar air flow systems. 42.2% of respondents routinely used exhaust suits. 68.1% of respondents routinely used impermeable disposable gowns. All surgeons use some form of anti-thromboembolic prophylaxis. 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin. 93.7% of surgeons routinely use antibiotic-loaded cement. The PFC and Kinemax prostheses were the most commonly used pros-theses. Interestingly, 97.7% of all first choice implants were cemented. Only 2 surgeons used uncemented TKR. 69.8% of surgeons used a posterior cruciate retaining design. A midline longitudinal skin incision is used by 87.2% of surgeons, a medial longitudinal skin incision by 7.0% and a lateral longitudinal skin incision by 5.8% 0f surgeons. A medial parapatellar capsular incision is preferred by 91.9% with the remainder using mid vastus or trivector retaining capsulotomy. Closure of capsulotomies is performed in flexion by 65.1% and in extension by 34.9%. In patients with osteoarthritis 38.4% routinely resurfaced the patella, 34.9% never resurfaced the patella and 26.7% selectively resurfaced. This was in direct contrast to practice for patients with rheumatoid arthritis in whom 66.3% routinely resurfaced the patella, 22.1% never resurfaced the patella and 11.6% selectively resurfaced.

This study has demonstrated considerable variation of practice in hip arthroplasty across the North West region and significant divergence from the BASK/BOA statement of best practice. The introduction of a properly funded national arthroplasty register will surely help to clarify the effect of such diverse practice on patient outcome.

Aim: To assess the factors affecting cup survivorship in cemented Total Hip Replacements carried out for DDH.

Methods: A retrospective study of 292 cemented total hip replacements carried out at Wrightington. The hips were classified according to the Crowe and Hartofilakidis classifications. Revision was used as the end point for prosthetic survivorship. The results were analysed statistically using SPSS for Windows.

Results: The mean age at time of surgery was 42.6 years with a mean follow-up of 15.7 years. The acetabulum was grafted in 48 cases. The commonest cause for revision was aseptic loosening of the acetabular component (88.3%). There was a higher rate of premature failure of the acetabular component with increasing severity of hip dysplasia, especially after 10years. There was a correlation with age of the patient, accelerated socket wear and previous pelvic osteotomy. There were higher rates of failure with the Charnley CDH stem and the offset bore cup.

Conclusion: Factors having an adverse effect on cup survival are severity of hip dysplasia, younger age at time of primary surgery, accelerated polyethylene wear and previous pelvic osteotomy. Bone grafting of the acetabulum and the operating surgeon did not influence long term cup survival.

We have assessed the long-term results of 292 cemented total hip replacements which were performed for developmental dysplasia of the hip in 206 patients. The mean age of the patients at operation was 42.6 years (15.9 to 79.5) and most (202) were women. The severity of dysplasia was graded according to both the Crowe and the Hartofilakidis classifications. A 22.25-mm Charnley head was always used and the acetabular components were inserted with cement into the true acetabulum. Bone grafting of the acetabulum, using the patient’s own femoral head, was performed on 48 occasions.

At a mean follow-up of 15.7 years (2.2 to 31.2) the overall survival of the acetabular component was 78%. The main cause of revision was aseptic loosening (88.3%). The rate of survival at 20 years based on the Hartofilakidis classification was 76% in the dysplastic, 55% in the low-dislocation and 12% in the high-dislocation groups and on the Crowe classification, 72.7% for group I, 70.7% for group II, 36.7% for group III and 15.6% for group IV. There was no statistical correlation between bone grafting of the acetabulum and survival of the acetabular component. This study has shown a higher rate of failure of the acetabular component with increasing severity of hip dysplasia.