Background: Recent studies have shown that local infiltration analgesia (LIA) improves outcome after total hip replacement (THA). No detailed information does exist to its influence on length of stay (LOS) after surgery. In this study we have evaluated LOS, pain treatment, mobilization, postoperative nausea and vomiting (PONV) and satisfaction in a period before and after implementing LIA in our department.

Patients and Methods: Patients diagnosed with primary osteoarthrosis of the hip scheduled for unilateral uncemented or hybrid THA were included in the study. All cases were recognized from a local database with prospective collected data on all patients undergoing THA in our department. Total 100 consecutive patients who did not have LIA from September 1st 2006 were compared with 100 consecutive patients who received LIA from September 1st 2007. The two groups were unmatched and no patients were excluded. The solution used for LIA consisted of 200 mg Ropivacain, 30 mg Ketorolac and 1 mg Adrenaline dissolved in 100 ml isotone NaCl.

Results: Patients in the two groups were similar in regard to gender, age, body mass index (BMI) and ASA group, but did differ in duration of the surgical approach, the latter group having treatment with LIA in average had a 20 minuts shorter surgical approach. The patients who received LIA had reduced LOS, mean 3.8 days compared to 5.1 days in the gropu not treated with LIA (p< 0.001). Moreover, patients treated with LIA were significant more satisfied (p< 0.05) compared to the group who did not receive LIA. Moreover, patients treated with LIA were more frequently mobilized on day 1 after surgery (p< 0,001) and day 3 as well (p< 0.05). Also, patients treated with LIA had significantly reduced PONV on the day of operation (p< 0.05) and well as they consumed more nutrition (p< 0.001) the day after the operation. There was no difference in pain-score between the two groups except on day 3 (p< 0.05) in activity and at rest on the day of discharge (p< 0.05). No wound complications could be shown in any of the groups during the first 6 weeks after surgery.

Interpretation: Introducing LIA in our department changed the postoperative period detailed in several ways for patients undergoing THA. This study document that operative wound infiltration with multimodal drugs reduced LOS after THA, even though the reduced duration of operation may be some of the explanation. Moreover, LIA resulted in better mobilisation, less PONV and more satisfied patients. We recommend all unit undertaking THA to implement LIA in their daily praxis.

Introduction: There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MonM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MonM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MonM patients may be undiagnosed ALVAL. At our single centre we have reviewed and compared three types of MonM articulations to examine the incidence of ALVAL and to identify trends.

Methods: The resurfacing group comprised 250 patients with the ASR prosthesis. In the resurfacing hybrid total hip replacement (THR) group there were 86 patients implanted with an ASR head on a stem. The final group comprised of 625 patients with a MonM THR using a 36mm Pinnacle head. Both the S-ROM and the Corail stems were used in the THR groups. Patients with persisting and activity-restricting groin pain had tests for infection. Patients were counselled and revision was offered if ALVAL was suspected from the clinical picture, blood results and the aspiration result. Specimens for microbiological and histological analysis were taken at the time of revision.

Results: We found 5 cases of histologically proven ALVAL in the absence of infection in 961 patients. The incidence was: 1.2% in the resurfacing group, 2.3% of Resurfacing Hybrid THR group and 0 in the 36 mm THR group. All 5 cases were in female patients. Only 1 case had any radiological abnormality. One patient was initially revised from a resurfacing to a 36mm MonM THR without clinical success. All patients have now been revised to ceramic-on-ceramic bearings with improvements in outcome.

Discussion: ALVAL may be under-diagnosed. The 5 patients we describe showed good clinical recovery following their primary procedure. However, activity levels decreased and pain increased at 6–12 months post-op. All described non-specific systemic symptoms. On examination, a painful straight leg raise was a characteristic finding. This may result from the significant effusion found around the hip at each revision. Fluid aspirated from these hips was of a characteristic colour (green grey) and viscosity. The failure of the revision of a resurfacing to a smaller MonM bearing highlights the problem of sensitisation to the metal debris. Any subsequent revision to a MonM bearing is unlikely to improve clinical outcome. This finding is consistent with previous reports in the literature. Our results suggest the incidence of ALVAL may be higher that previously thought. We suggest all patients with significant groin pain should have inflammatory markers tests and a hip aspiration performed. In the absence of infection, revision to an alternative bearing surface may be indicated.