Efficacy of acute care pathways for older patients: a systematic review and meta-analysis.

Meeting the needs of acute geriatric patients is often challenging, and although evidence shows that older patients need tailored care, it is still unclear which interventions are most appropriate. The objective of this study is to systematically evaluate the hospital-wide acute geriatric models compared with conventional pathways. The design of the study includes hospital-wide geriatric-specific models characterized by components including patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment, and follow-up after discharge. Primary and secondary outcomes were considered, including functional decline, activities of daily living (ADL), length-of-stay (LoS), discharge destination, mortality, costs, and readmission. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of 20 studies reporting on 15 trials and acutely admitted patients with an average age of 79, complex conditions and comorbidities to acute geriatric-specific pathways (N = 13,595) were included. Geriatric-specific models were associated with lower costs (weighted mean difference, WMD = - $174.98, 95% CI = -$332.14 to - $17.82; P = 0.03), and shorter LoS (WMD = - 1.11, 95% CI = - 1.39 to - 0.83; P < 0.001). No differences were found in functional decline, ADL, mortality, case fatalities, discharge destination, or readmissions. Geriatric-specific models are valuable for improving patient and system-level outcomes. Although several interventions had positive results, further research is recommended to study hospital-wide geriatric-specific models. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00743-w.

Impact of smoking on pain and function in rotator cuff repair: a prospective 5-year cohort follow-up of 1383 patients.

BACKGROUND: This multicentre cohort study investigates the effect of smoking on the outcome of rotator cuff repair (RCR), with attention to age at presentation for surgery, pre-operative and post-operative pain and function and intra-operative findings. METHODS: Patient information was collected pre-operatively, including Flex Shoulder Function (Flex SF) and visual analogue scale pain, then at 6 months, 1, 2 and 5 years post-operatively. Intra-operative technical data were collected by the operating surgeon. Current smokers were classified by daily cigarette consumption. RESULTS: A total of 1383 RCRs in as many patients were included with an 84% 5-year follow-up. Smokers were on average 6.7 years younger than non-smokers (51.8 vs. 58.5, P < 0.001). There was no difference in intra-operatively assessed tear size both in anteroposterior dimension (P = 0.5) and retraction (P = 0.9). Pre-operative Flex SF score in smokers was below that of non-smokers (23.0 vs. 24.5, P = 0.002) and at 6 months (P = 0.02) but no different at 5 years (P = 0.7). Pain scores were higher in smokers than non-smokers both pre-operatively (5.34 vs. 4.67, P < 0.001) and up to 2 years (P < 0.001) but not at 5 years (P = 0.073). CONCLUSION: Smokers undergoing RCR were younger than non-smokers, and had worse pre-operative pain scores and shoulder function. Poorer post-operative function persisted to 6 months, and with higher reported pain to 2 years in smokers. However, at 5-year follow-up, patient-reported outcomes were not affected by smoking status.

Optimal plate fixation of distal femoral fractures in the presence of a well fixed cemented hip arthroplasty femoral stem.

INTRODUCTION: The requirement for lateral plate fixation in the presence of a hip arthroplasty stem is increasing, yet the optimal plate construct necessary to reduce inter-prosthetic strain and prevent subsequent fractures is unknown. Therefore, the purpose of this study was to determine the optimal position of a lateral femoral plate in relation to a femoral stem. METHODS: We used 4th Generation Composite Sawbones®, a collarless polished cemented femoral stem and a broad Peri-loc™ plate with varying overlap of the stem. Each construct was subjected to torsion, axial compression and 3-point lateral bending, with the strain measured at the tip of the femoral stem and the force-to-failure recorded. RESULTS: In all three loading directions a plate, which extended at least two shaft diameters proximal to the tip of the stem, experienced the lowest strain ( p < 0.001). Constructs with no overlap, and particularly those with a small gap between the tip of the stem and the proximal extent of the plate experienced the highest strain ( p < 0.001). This high strain resulted in lower forces required to cause fracture in the clinically significant scenarios of femoral torsion and lateral bending. CONCLUSIONS: Optimal plate fixation is achieved by extending a lateral femoral plate at least two shaft diameters proximal to the tip of the stem and using a spread of proximal screws. Distal fixation increases the strain experienced at the tip of the stem and higher strains are noted the smaller the gap between the proximal extent of the femoral plate and the tip of stem.

Lower Extremity Lateral Skin Stretch Perception for Haptic Feedback.

Tactile feedback in recent decades has allowed humans to receive information through technology beyond traditional visual and auditory senses. Lateral skin stretch has the potential to be a mode of tactile feedback, reliably enabling the perception of directional cues through the use of a single actuator. Experiments were conducted to explore sensitivity to skin stretch on nine locations on the human lower leg. Thirty-two stimuli were presented to subjects, exploring effects of displacement (from 0.2-2.0 mm) and speed (from 0.5-4.0 mm/s) on the perception of left and right directions. Higher accuracy came from stimuli having higher displacements and speeds. Three of the locations: soleus, calcaneal tendon (upper), and fibularis longus (lower) all had a mean accuracy of at least 85 percent and are suitable locations for a skin stretch tactile feedback device.

Propionibacterium acnes in primary shoulder arthroplasty: rates of colonization, patient risk factors, and efficacy of perioperative prophylaxis.

BACKGROUND: Recent literature has shown that Propionibacterium acnes can be cultured from superficial and deep layers of the shoulder. Our aims were to assess the rate of P. acnes colonization in patients undergoing primary shoulder arthroplasty, to identify patient-related risk factors, and to evaluate the efficacy of our perioperative antisepsis protocol. METHODS: Thirty consecutive patients undergoing primary shoulder arthroplasty were included in our study. Swabs were taken perioperatively (4 superficial and 2 deep wound swabs) and analyzed quantitatively for P. acnes. Cefazolin minimum inhibitory concentration was determined for P. acnes isolates from positive deep cultures. RESULTS: Twenty-two patients (73%) had positive cultures for P. acnes. Male gender (P = .024) and presence of hair (P = .005) had significantly higher rates of P. acnes superficial cultures. Subjects with positive superficial P. acnes cultures (P = .076) and presence of hair with a history of steroid injection (P = .092) were more likely to have deep P. acnes-positive cultures, but this was not statistically significant. Local topical antisepsis measures did not eradicate P. acnes (P = .12). Mean cefazolin minimum inhibitory concentration for P. acnes was 0.32 µg/mL. CONCLUSION: P. acnes is commonly isolated from the skin and deep surgical wounds of patients undergoing primary total shoulder arthroplasty who have not had previous shoulder surgery. Male gender and presence of hair were significant risk factors for P. acnes colonization. Perioperative local topical antisepsis and cefazolin administration were not effective in eliminating P. acnes colonization.

Examination of the Effects of Heterogeneous Organization of RyR Clusters, Myofibrils and Mitochondria on Ca2+ Release Patterns in Cardiomyocytes.

Spatio-temporal dynamics of intracellular calcium, [Ca2+]i, regulate the contractile function of cardiac muscle cells. Measuring [Ca2+]i flux is central to the study of mechanisms that underlie both normal cardiac function and calcium-dependent etiologies in heart disease. However, current imaging techniques are limited in the spatial resolution to which changes in [Ca2+]i can be detected. Using spatial point process statistics techniques we developed a novel method to simulate the spatial distribution of RyR clusters, which act as the major mediators of contractile Ca2+ release, upon a physiologically-realistic cellular landscape composed of tightly-packed mitochondria and myofibrils. We applied this method to computationally combine confocal-scale (~ 200 nm) data of RyR clusters with 3D electron microscopy data (~ 30 nm) of myofibrils and mitochondria, both collected from adult rat left ventricular myocytes. Using this hybrid-scale spatial model, we simulated reaction-diffusion of [Ca2+]i during the rising phase of the transient (first 30 ms after initiation). At 30 ms, the average peak of the simulated [Ca2+]i transient and of the simulated fluorescence intensity signal, F/F0, reached values similar to that found in the literature ([Ca2+]i ≈1 µM; F/F0≈5.5). However, our model predicted the variation in [Ca2+]i to be between 0.3 and 12.7 µM (~3 to 100 fold from resting value of 0.1 µM) and the corresponding F/F0 signal ranging from 3 to 9.5. We demonstrate in this study that: (i) heterogeneities in the [Ca2+]i transient are due not only to heterogeneous distribution and clustering of mitochondria; (ii) but also to heterogeneous local densities of RyR clusters. Further, we show that: (iii) these structure-induced heterogeneities in [Ca2+]i can appear in line scan data. Finally, using our unique method for generating RyR cluster distributions, we demonstrate the robustness in the [Ca2+]i transient to differences in RyR cluster distributions measured between rat and human cardiomyocytes.

Does adjustable-loop femoral cortical suspension loosen after anterior cruciate ligament reconstruction? A retrospective comparative study.

BACKGROUND: Recent biomechanical research has suggested that adjustable-loop graft suspension constructs in anterior cruciate ligament (ACL) reconstruction may loosen after deployment. Our objective was to compare short-term knee stability and graft failure rate between adjustable-loop and fixed-loop femoral cortical suspension in patients undergoing primary ACL reconstruction. METHODS: A consecutive series of 188 patients who underwent primary ACL reconstruction using hamstrings autograft by a single surgeon were divided into two groups; 73 received adjustable-loop (TightRope RT (Arthrex Inc., Naples, FL)) and 115 received fixed-loop (RetroButton (Arthrex Inc., Naples, FL)) femoral cortical suspension. The two groups were compared at six months, one year, and two years postoperatively using KT-1000 arthrometer testing and graft failure rate (revision surgery, grade 2+ Lachman test, any pivot shift, >5mm side-to-side KT-1000 difference). RESULTS: There was no significant difference between the two groups in maximum side-to-side difference in KT-1000 testing at six months (mean 1.51mm (adjustable-loop group) vs. 1.79mm (fixed-loop group), p=0.23), one year (mean 1.44mm vs. 1.64mm, p=0.48), or two years (mean 1.14mm vs. 1.07mm, p=0.90) postoperatively. There was no significant difference between the two groups in rate of graft failure (10% vs. 11%, p=0.71) or timing of graft failure in affected patients (mean 11.4months vs. 13.8months, p=0.51). CONCLUSIONS: We found no significant difference in postoperative knee stability or graft failure rate between adjustable-loop and fixed-loop femoral cortical suspension in patients undergoing primary ACL reconstruction. Our results suggest that adjustable-loop suspension does not clinically loosen after ACL reconstruction. LEVEL OF EVIDENCE: III (retrospective cohort study).

Altered load transfer in the pelvis in the presence of periprosthetic osteolysis.

Periprosthetic osteolysis in the retroacetabular region with cancellous bone loss is a recognized phenomenon in the long-term follow-up of total hip replacement. The effects on load transfer in the presence of defects are less well known. A validated, patient-specific, 3D finite element (FE) model of the pelvis was used to assess changes in load transfer associated with periprosthetic osteolysis adjacent to a cementless total hip arthroplasty (THA) component. The presence of a cancellous defect significantly increased (p < 0.05) von Mises stress in the cortical bone of the pelvis during walking and a fall onto the side. At loads consistent with single leg stance, this was still less than the predicted yield stress for cortical bone. During higher loads associated with a fall onto the side, highest stress concentrations occurred in the superior and inferior pubic rami and in the anterior column of the acetabulum with larger cancellous defects.

Finite element analysis of retroacetabular osteolytic defects following total hip replacement.

Periprosthetic osteolysis in the retroacetabular region with cancellous bone loss is a recognized phenomenon in the long-term follow-up of total hip replacement. The effects on load transfer in the presence of defects are less well known. A finite element model incorporating a retroacetabular defect behind a cementless component was validated against a 4th generation sawbone pelvis. Computational predictions of surface strain and von Mises stresses were closely correlated to experimental findings. The presence of a cancellous defect increased von Mises stress in the cortical bone of the medial wall of the pelvis. At a load of 600 N this was under the predicted failure stress for cortical bone. Increases in the cup size relative to the acetabulum caused increased stress in the cortical bone of the lateral wall of the pelvis, adjacent to the acetabulum. We are confident that our modeling approach can be applied to patient specific defects to predict pelvis stress with large loads and a range of activities.

Comparison of functional outcomes of reverse shoulder arthroplasty with those of hemiarthroplasty in the treatment of cuff-tear arthropathy: a matched-pair analysis.

BACKGROUND: Rotator cuff-tear arthropathy has traditionally represented a challenge to the shoulder arthroplasty surgeon. The poor results of conventional total shoulder arthroplasty in rotator-cuff-deficient shoulders due to glenoid component loosening have led to hemiarthroplasty being the traditional preferred surgical option. Recently, reverse total shoulder arthroplasty has gained increasing popularity because of a clinical perception of an improved functional outcome, despite the lack of comparative data. The aim of this study was to compare the early functional results of hemiarthroplasty with those of reverse shoulder arthroplasty in the management of cuff-tear arthropathy. METHODS: The results of 102 primary hemiarthroplasties for rotator cuff-tear arthropathy were compared with those of 102 reverse shoulder arthroplasties performed for the same diagnosis. Patients were identified from the New Zealand Joint Registry and matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford Shoulder Scores (OSS) collected at six months postoperatively as well as mortality and revision rates were compared between the two groups. RESULTS: There were fifty-one men and fifty-one women in each group, with a mean age of 71.6 years in the hemiarthroplasty group and 72.6 years in the reverse shoulder arthroplasty group. The mean OSS at six months was 31.1 in the hemiarthroplasty group and 37.5 in the reverse shoulder arthroplasty group. At the time of follow-up, there were nine revisions in the hemiarthroplasty group and five in the reverse shoulder arthroplasty group. No difference in mortality rate was seen between the two groups. CONCLUSIONS: In this unselected population with rotator cuff-tear arthropathy, controlled for age, sex, and ASA score, reverse shoulder arthroplasty resulted in a functional outcome that was superior to that of hemiarthroplasty. Longer-term follow-up is needed to confirm these findings.

Proximal tibial bone density is preserved after unicompartmental knee arthroplasty.

BACKGROUND: Bone mineral density (BMD) in the proximal tibia decreases after TKA and is believed to be a factor in implant migration and loosening. Unicompartmental knee arthroplasty (UKA) is a less invasive procedure preserving knee compartments unaffected by degeneration. Finite element studies have suggested UKA may preserve BMD and that implants of differing stiffnesses might differentially affect BMD but these notions have not been clinically confirmed. QUESTIONS/PURPOSES: We therefore asked whether (1) proximal tibial BMD decreases after UKA, and (2) a cemented metal tibial component with a mobile polyethylene (PE) bearing would have greater BMD loss than a cemented PE tibial component. METHODS: We prospectively followed 48 patients who underwent 50 UKAs using one of two implants: one with a cemented metal tibial baseplate and a mobile PE insert (n = 26) and one with a cemented all-PE tibial component (n = 24). In followup we assessed pain and function (Oxford Knee Score, SF-12, The Knee Society Score(©)) and radiographs. BMD changes were assessed using quantitative CT osteodensitometry performed postoperatively and at 1 and 2 years after the index procedure. RESULTS: Mean cancellous BMD decreased 1.9% on the medial side and 1.1% on the lateral side. Mean cortical BMD was static, decreasing 0.4% on the medial side and increasing 0.5% on the lateral side. The greatest observed difference between implants for any region was 3.7%. There were no differences in pain or functional outcome scores. CONCLUSIONS: BMD was preserved 2 years after UKA with no major differences seen between implant types.

The paediatric Bohler's angle and crucial angle of Gissane: a case series.

BACKGROUND: Bohler's angle and the crucial angle of Gissane can be used to assess calcaneal fractures. While the normal adult values of these angles are widely known, the normal paediatric values have not yet been established. Our aim is to investigate Bohler's angle and the crucial angle of Gissane in a paediatric population and establish normal paediatric reference values. METHOD: We measured Bohler's angle and the crucial angle of Gissane using normal plain ankle radiographs of 763 patients from birth to 14 years of age completed over a five year period from July 2003 to June 2008. RESULTS: In our paediatric study group, the mean Bohler's angle was 35.2 degrees and the mean crucial angle of Gissane was 111.3 degrees. In an adult comparison group, the mean Bohler's angle was 39.2 degrees and the mean crucial angle of Gissane was 113.8 degrees. The differences in Bohler's angle and the crucial angle of Gissane between these two groups were statistically significant. CONCLUSION: We have presented the normal values of Bohler's angle and the crucial angle of Gissane in a paediatric population. These values may provide a useful comparison to assist with the management of the paediatric calcaneal fracture.

Osteopontin is required for unloading-induced osteoclast recruitment and modulation of RANKL expression during tooth drift-associated bone remodeling, but not for super-eruption.

Unloading of teeth results in extensive alveolar bone remodeling, causing teeth to move in both vertical ("super-eruption") and horizontal direction ("drift"). In order to decipher the molecular mechanisms of unloading-induced bone remodeling during tooth movement, we focused on the role of osteopontin (OPN) in the un-opposed molar model, comparing wild-type (WT) and OPN-null mice. Our data indicated that OPN was not required for the continuous eruption of un-opposed teeth while OPN was necessary for the drift of teeth. OPN expression and osteoclast counts were greatly increased on alveolar bone surfaces facing the direction of the drift in WT mice, while osteoclast counts were diminished in OPN-/- mice. RANKL expression in the distal periodontal ligament of WT molars increased significantly by day 6 following unloading, while overall levels of RANKL expression were decreased in both WT and OPN-null mice. In vitro treatment of MC3T3 cells, WT BMCs and OPN-/- BMCs with recombinant OPN resulted in significantly increased RANKL expression in all three cell types. The PI3K and MEK/ERK pathway inhibitors Ly294002 and U0126 reduced RANKL expression levels in vitro. Treatment of BMCs and MC3T3 with OPN also resulted in increased ERK phosphorylation and reduced OPG levels. Together, our studies suggest that increased OPN expression during unloading-induced drifting of teeth enhances localized RANKL expression and osteoclast activity on drift-direction alveolar bone surfaces via extracellular matrix signaling pathways.

Ponseti method compared with surgical treatment of clubfoot: a prospective comparison.

BACKGROUND: Current trends in the treatment of idiopathic clubfoot have shifted from extensive surgical release to more conservative techniques. The purpose of the present study was to prospectively compare the results of the Ponseti method with those of surgical releases for the correction of clubfoot deformity. METHODS: We prospectively compared patients who had idiopathic clubfoot deformities that were treated at a single institution either with the Ponseti method or with below-the-knee casting followed by surgical release. The clinical records of the patients with a minimum duration of follow-up of two years were reviewed. All scheduled and completed operative interventions and associated complications were recorded. RESULTS: Fifty-five patients with eighty-six clubfeet were treated; forty feet were included in the group that was treated with the Ponseti method, and forty-six feet were included in the group that was treated with below-the-knee casts followed by surgery (with three of these feet requiring casting only). There was no difference between the groups in terms of sex, ethnicity, age at the time of first casting, pretreatment Pirani score (average, 5.2 in both groups), or family history. The average number of casts was six in the Ponseti group and thirteen in the surgical group. Of the feet that were treated with below-the-knee casts, forty-three underwent surgery, with forty-two undergoing major surgery (posterior release [eleven] or posteromedial release [thirty-one]). In the Ponseti group, fourteen feet required fifteen operative interventions for recurrences, with only one foot requiring revision surgery. Four of these fifteen were major (necessitating posterior [one] or posteromedial release [three]) while eleven were minor. Thirteen feet in the surgical group required fourteen surgical revisions. Two postoperative complications were seen in each group. CONCLUSIONS: While both cohorts had a relatively high recurrence rate, the Ponseti cohort was managed with significantly less operative intervention and required less revision surgery. The Ponseti method has now been adopted as the primary treatment for clubfoot at our institution.

Functional anatomy of the lymphatics draining the skin: a detailed statistical analysis.

Relatively little is known about the functional anatomy of the lymphatic vessels draining the skin. To address this issue, we previously created a three-dimensional computer model of skin lymphatic drainage, using melanoma lymphoscintigraphy (LS) data from 5232 patients. In this study we sought to extend our model by performing a detailed statistical analysis of the mapped LS data to characterize the functional anatomy of the superficial lymphatics without any a-priori spatial bias. We investigated the commonly held assumption that lymphatic drainage is symmetric between the two sides of the body. Results indicated that, with the exception of the lower anterior torso, posterior leg and a small section of the posterior torso, most skin regions with sufficient data showed symmetric drainage. LS data from each symmetric skin region were then reflected to the opposite side of the body to provide an increased LS dataset for subsequent analysis. Cluster analysis was then applied to this reflected LS dataset to group regions of skin that drained in a similar manner. Results defined nine large clusters of skin, largely draining to the dominant axillary, groin, cervical level II and preauricular node fields. Each of the four axillary and groin node fields defined large clusters of skin on the torso, dividing it into regions similar to the historical 'Sappey's lines', although a fifth region of highly ambiguous drainage was also shown in the anterior and posterior center of the torso. Collectively, these results provide important new insights into skin lymphatic drainage, both improving and quantifying our understanding of functional lymphatic anatomy.

Loss of tibial bone density in patients with rotating- or fixed-platform TKA.

Little is known about tibial bone remodeling with TKA and its clinical relevance. We performed a randomized clinical trial to compare tibial bone density changes in cemented components with different bearing designs. Bone density changes were assessed using quantitative computed tomography (qCT)-assisted osteodensitometry. Twenty-eight rotating-platform and 26 fixed-platform cemented TKAs were included. The nonoperated contralateral side was used as a control. CT scans were performed postoperatively and 1 year and 2 years after the index operation. Cancellous bone density loss (up to 12.6% at 2 years) was observed in all proximal tibial regions in both cohorts. In contrast, we found lower cortical bone density loss (up to 3.6% at 2 years). We found no differences in bone loss between fixed- and rotating-platform implants. The decrease of cancellous bone density after TKA suggests stress transfer to the cortical bone.

Functional outcome of femoral peri prosthetic fracture and revision hip arthroplasty: a matched-pair study from the New Zealand Registry.

BACKGROUND AND PURPOSE: The number of periprosthetic fractures following total hip arthroplasty (THA) is increasing. There is, however, limited data on the functional outcome following these injuries. We analyzed functional outcome for revision THA following periprosthetic fracture, and compared this to the outcome of elective revision THA performed for aseptic loosening. METHODS: 232 patients undergoing revision THA for femoral fracture were identified from the New Zealand National Registry. Functional outcome was measured using the Oxford 12 hip score (OHS). A reference group of 232 patients undergoing elective revision THA was selected and matched for age and sex. RESULTS: Outcome was worse following revision THA for periprosthetic fracture than in reference patients (mean OHS: 29 vs. 24, p = 0.006). A higher 6-month mortality rate was seen in periprosthetic fracture patients (7.3% vs. 0.9%, p < 0.001), along with a higher likelihood of re-revision (7.3% vs. 2.6%, p = 0.06). INTERPRETATION: This large comparative series of periprosthetic fractures following THA shows that patients with periprosthetic fracture have poorer functional outcome and higher death rates than patients undergoing revision THA for aseptic loosening.

RANKL, osteopontin, and osteoclast homeostasis in a hyperocclusion mouse model.

The biological mechanisms that maintain the position of teeth in their sockets establish a dynamic equilibrium between bone resorption and apposition. In order to reveal some of the dynamics involved in the tissue responses towards occlusal forces on periodontal ligament (PDL) and alveolar bone homeostasis, we developed the first mouse model of hyperocclusion. Swiss-Webster mice were kept in hyperocclusion for 0, 3, 6, and 9 d. Morphological and histological changes in the periodontium were assessed using micro-computed tomography (micro-CT) and ground sections with fluorescent detection of vital dye labels. Sections were stained for tartrate-resistant acid phosphatase, and the expression of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteopontin (OPN) was analyzed by immunohistochemistry and real-time polymerase chain reaction (PCR). Traumatic occlusion resulted in enamel surface abrasion, inhibition of alveolar bone apposition, significant formation of osteoclasts at 3, 6 and 9 d, and upregulation of OPN and RANKL. Data from this study suggest that both OPN and RANKL contribute to the stimulation of bone resorption in the hyperocclusive state. In addition, we propose that the inhibition of alveolar bone apposition by occlusal forces is an important mechanism for the control of occlusal height that might work in synergy with RANKL-induced bone resorption to maintain normal occlusion.

Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: a national survey.

Five hundred orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty surgery. Seventy-two percent of surgeons and 73% of anaesthetists responded to the survey. In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below a haemoglobin (Hb) level of 8 g/dL. Surgeons tended to be more aggressive in their attitudes, with a mean transfusion threshold of 8.3 g/dL compared to 7.9 g/dL for anaesthetists (p<0.01), and with 97% of surgeons transfusing two or more units compared to 78% of anaesthetists (p<0.01). This threshold Hb increased if the patient was symptomatic (surgeons 9.3 g/dL, anaesthetists 8.8 g/dL, p<0.05) or was known to have pre-existing ischaemic heart disease (surgeons 9.0 g/dL, anaesthetists 9.2 g/dL, p<0.05). A wide variability in attitudes and practices is demonstrated, and the development and adoption of consensus guidelines needs to be encouraged if efforts to reduce the use of blood products are to succeed.