Background: Falls are a major concern in the elderly population both from a clinical perspective and that of health resource provision. This study evaluates the incidence of falls in patients awaiting hip or knee replacement and the impact of joint replacement surgery 2 years later.

Method: Patients aged 65-80 years listed for primary hip or knee arthroplasty for osteoarthritis (OA) were invited to participate. Patients completed a questionnaire including Western Ontario and McMaster University OA Index (WOMAC) scores 0-100, 100 best, history of falls and fractures. Function was measured using Timed Up and Go (TUG) walk test. All tests were repeated at two years.

Results: One hundred and ninety-nine patients (84 hips, 115 knees) were recruited with a mean age of 72 years (standard deviation 4.0) and predominantly female (57 %). At two years 144 patients were reviewed of whom 128 had undergone arthroplasty. After surgery, 29/128 (23%) reported falling compared to 55 of these 128 (43%) falling at baseline; only 13/128 (11%) had fallen more than once. Fifteen patients sustained minor injuries and one patient reported a fractured wrist. Of the patients who had undergone joint replacement and fell at baseline 36/55 (66%) patients reported no falls at follow-up, whilst there were 11 new fallers. Patients reporting falls had significantly lower WOMAC pain and function scores, and slower TUG scores at both baseline and two-year review.

Conclusion: Patients with severe hip and knee OA awaiting arthroplasty reported a higher incidence of falls compared to the normal population but reported fewer falls after surgery. However, almost one in four patients were still reporting falling at the two-year review. Injury including periprosthetic fractures can have serious clinical and economic consequences. This study highlights the need to evaluate a falls prevention programme in arthroplasty management.

Background and objective: in 2003 in its publication ‘Care of fragility fracture patients’ The British Orthopaedic Association highlighted the orthopaedic surgeon’s role in assessment and management of patients at high risk from osteoporosis. In general such secondary prevention of osteoporosis is carried out poorly by orthopaedic surgeons. This audit aimed to determine if software which identifies patients at high risk from osteoporosis from clinic letters, improves orthopaedic surgeons’ referral rates for DEXA.

Methods: two audit cycles were carried out using local guidelines. The audits concerned patients over 50 years having sustained a fragility fracture of the distal radius. According to local guidelines all such patients should undergo DEXA. Patients were identified from hospital records and the number referred for DEXA determined. Those who had undergone DEXA in the year prior to fracture were excluded. The baseline audit was from April to June 2004 inclusive followed by closure of the loop between October and December 2004 following reinforcement of guidelines. Following continued poor referral rates at this point the software programme was introduced. It identifies patient age and key words in dictated clinic letters when they are being printed, for example distal radial fracture. Appropriate patients have computer generated osteoporosis advice included at the bottom of the general practitioner letter along with a DEXA referral form which General Practitioners complete. A further audit using similar methods was carried out 3 months after the software introduction (January 2006).

Results: baseline audit identified forty-three patients (36 women and 7 men) with a mean age of 73 years, 3 were referred for DEXA (7%). Following reinforcement of guidelines fifty-two patients were identified (46 women and 6 men) with a mean age of 68 years, 16 (31%) were referred. At re-audit (following the introduction of the software programme) 45 patients were identified (38 women and 7 men) with an average age of 71 years. 30 (67%) were referred for DEXA. This is a significant improvement using a Chi squared analysis.

Conclusion: the software programme significantly improves orthopaedic surgeon identification of patients at high risk of osteoporosis and referral rates for DEXA.

This study aimed to determine the prevalence of osteoporosis in patients awaiting hip and knee replacement for osteoarthritis and to review them two years later to determine the changes in bone density following joint replacement.

Patients aged between 65 and 80 years awaiting total hip or knee replacement were invited to participate. Lumbar spine, bilateral femoral and forearm bone mineral density (BMD) measurements were obtained using dual energy x-ray absorptiometry. BMD values were standardised using previously published T-scores and Z-scores. To assess clinical status, patients completed a questionnaire including the Western Ontario and McMaster University OA Index (WOMAC). All measurements were repeated at two-years.

Participants included 199 patients (84 hips and 115 knees) with a mean age of 72 years (SD 4.0) and were predominantly female (hips 67%, knees 50%). At baseline 46/199 (23%) patients (39 females) had evidence of osteoporosis (WHO definition) at one or more sites with the highest prevalence at the forearm (14%). At two-years 144 patients attended for review with 128 having undergone hip (56) or knee (72) replacement. At this review 39/144 (27%) patients (33 females) had evidence of osteoporosis at one or more sites with the highest prevalence at the forearm (22%). The greatest bone loss occurred at the forearm with median BMD change of minus 4% for females (25th percentile minus 7.3%, 75th percentile minus 1.9%) and minus 2.9% for males (25th percentile minus 4.6%, 75th percentile minus 1.1%). There was a significant difference in WOMAC Pain scores at follow-up between the osteo-porotic and non-osteoporotic knee patients (67 versus 81, p=0.002) indicating that osteoporotic patients had greater knee pain.

We have identified the forearm as not only the site with the highest prevalence of osteoporosis but also the greatest bone loss at follow-up. Further evaluation of forearm bone density measurements in the preopera-tive assessment and follow-up of patients awaiting joint replacement for hip and knee OA is required. Larger studies are needed to confirm our finding that the presence of osteoporosis is predictive of worse patient-reported outcomes of knee replacement.