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A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22).Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome.Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores.In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

INTRODUCTION: Revision hip surgery is well documented to have a high association with substantial blood loss and the associated need for a blood transfusion. This exposes the patient to increased risk of transfusion reaction and blood borne infection. There are many strategies to minimize allogeneic transfusion rates in revision surgery such as pre-operative autologous donation, peri-operative tranexamic acid, thrombin sealants, normovolaemic haemodilution, intra-operative blood salvage and the use of post-operative autologous drains. PATIENTS AND METHODS: We prospectively looked at 177 consecutive cases performed at one centre by a single surgical and anaesthetic team to identify which patient and operative factors were most significant in minimizing the requirement for an allogeneic blood transfusion. RESULTS: Our results identified the duration of surgery as being the only significant variable affecting the level of blood loss. We noted a 3% increase in the probability of massive blood loss (> 2000 mls) for every minute of increased surgical time in our series. CONCLUSIONS: We conclude that measures to minimize the duration of surgery would be beneficial in reducing blood loss and the risks of requiring blood transfusions in revision hip surgery.

OBJECTIVES To report the long-term functional outcome of a cohort of patients with operatively treated unstable pelvic fractures using validated patient-reported outcome measures. DESIGN Long-term observational study using prospective and retrospective data. SETTING Tertiary referral pelvic trauma center, Bristol, United Kingdom. PATIENTS Seventy-four polytraumatized patients with operatively treated unstable pelvic ring injuries (50 OTA/AO type B and 24 OTA/AO type C, mean Injury Severity Score 17) treated between 1994 and 2005. INTERVENTION Sixty-four (86%) patients were treated with internal fixation. The remaining 10 patients (14%) were treated with either combined percutaneous posterior fixation and anterior external fixation or external fixation in isolation. MAIN OUTCOME Patient-reported functional outcome. MEASUREMENTS Short Form-36, with UK norm-based comparator scores and EQ-5D-3L. RESULTS Patients were between 11 and 22 years after injury (mean 15 years). We found no significant association between fracture classification and outcome score, but compared with age- and sex-matched scores for a UK population, differences were statistically significant in 3 of the 8 domains of health: physical function (P = 0.04), bodily pain (P = 0.001), and vitality (P = 0.001). The level of disability remained constant for these patients compared with their patient-reported outcome measure scores reported 8 years previously. CONCLUSION Patients who sustain an unstable pelvic fracture continue to have significant functional limitations compared with an uninjured population. These changes were not found to be related to age, injury pattern, genitourinary injury, or neurological injury. Functional outcome scores did not change over the 2 long-term time points. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Achieving adequate surgical exposure is a key to successful implant removal and re-implantation during revision knee arthroplasty. This, however, has to be done with careful attention to the vital bony and soft tissue structures about the knee so that risks are minimized and long-term function is optimized. An in-depth understanding of the normal anatomy of the knee as well as the patho-anatomy in the revision setting will facilitate pre-operative planning, preservation of vital structures intra-operatively and anticipation of problems intra- and post-operatively so measures can be taken to forestall these. Standard approaches to the knee often fail to provide the access required for revision surgery, and extensile approaches may need to be deployed. A variety of extensile approaches are available to the surgeon, each with its merits and drawbacks. We present a concise review of the standard and extensile approaches deployed in revision knee surgery, with an overview of the relevant anatomy and an evidence base for the different extensile approaches.

Summary Background Clopidogrel is an anti-platelet agent which causes an increase in bleeding time. An increasing number of patients presenting with an acute femoral neck fracture take clopidogrel in combination with other anti-platelet agents as regular prescription medication. Such patients may be at higher risk of increased peri-operative bleeding. No guidelines or recommendations currently exist regarding the routine discontinuation of clopidogrel in patients with fracture of the femoral neck awaiting surgery. Methods A telephone questionnaire was undertaken to examine the current practice amongst 110 orthopaedic departments in the UK regarding the discontinuation of clopidogrel prior to trauma surgery for femoral neck fractures. This was compared to the practice of discontinuing aspirin and warfarin in the same patient groups in these departments. Results There appears to be significant variation in practice amongst orthopaedic departments with 43.6% having a policy of discontinuing clopidogrel. This compares to 37.3% of trusts having a policy of stopping aspirin and 97.3% stopping warfarin. Conclusion There is wide variation in practice regarding the discontinuation of clopidogrel preoperatively in patients due to undergo surgery for femoral neck fractures. These findings highlight the need to develop guidelines for the preoperative management of these patients.

Aims To examine variations and consistencies in the emergency management of distal radial fractures across England and Wales. Methods A survey was conducted of emergency departments (ED) in England and Wales regarding the acute management of patients with distal radius fractures. The study investigated the use of anaesthesia, the person performing both the anaesthetic and the manipulation, the use of resuscitation facilities and monitoring, the cast applied, the follow-up and the management of complex injuries or those in younger patients. Results Surveys were conducted in 105 units, giving a response rate of 91% of ED in England and Wales. The most frequent anaesthetic types were haematoma block (50%), intravenous benzodiazepines (20%), Bier9s block (17%) and a small minority using other techniques such as brachial plexus blocks (2%). Basic cardiorespiratory monitoring was variable, and 10% of trusts did not routinely monitor patients undergoing Bier9s blocks or manipulation with sedatives. Only 50% of ED would manipulate comminuted fractures or fractures in young adult patients. Conclusion There are significant regional variations. The use of monitoring is highly variable and there are no consistent standards when administering potentially potent anaesthetic medications. The low percentage of units attempting reduction of complex fractures or fractures in young patients will disadvantage training in ED as well as patients. Guidelines are required to improve care, which is highly inconsistent at present.