Femoroacetabular impingement syndrome (FAI) is a common cause of hip and groin pain in young adults. Physiotherapy and surgery have both been used to treat FAI syndrome, but there is no robust evidence of comparative effectiveness. UK FASHIoN compared the clinical and cost-effectiveness of arthroscopic hip surgery (HA) versus best conservative care in patients with FAI syndrome. UK FASHIoN was a pragmatic, multicentre, 2 parallel arm, superiority, randomised controlled trial in patients with FAI syndrome. Eligible patients were over 16 without radiographic signs of osteoarthritis, deemed suitable for arthroscopic FAI surgery. Participants were randomly allocated to HA or Personalised Hip Therapy (PHT - a physiotherapist-led programme comprising 6 to 10 sessions). The primary outcome measure was hip-related quality of life using the patient-reported International Hip Outcome Tool (iHOT-33) at 12 months. Secondary outcomes included EQ5D5L, SF12, adverse events, and cost-effectiveness. Primary analysis compared differences in iHOT-33 scores at 12 months by intention to treat.Purpose
Methods
There is a 20% dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied postoperatively have been widespread. However, it is unclear what sort of information patients would want from such a tool, how it would affect their decision making process, and at what part of the pathway such a tool should be used. Using focus groups involving 12 participants and in-depth interviews with 10 participants, we examined the effect outcome prediction has by providing fictitious predictions to patients at different stages of treatment. A qualitative analysis of themes, based on a constant comparative method, is used to analyse the data. This study was approved by the Dyfed Powys Research Ethics Committee (13/WA/0140).Background
Methods
Knee replacement surgery is currently facing three dilemmas: a high dissatisfaction rate; increasing demand with financial constraints; and variation in utilisation. A patient centred approach, usually achieved through shared decision-making, has the potential to help address these dilemmas. However, such an approach requires an understanding of the factors involved in patient decision-making. This is the first study examining decision-making in knee replacements that includes patients at different stages of decision-making – this is critical when considering decision-making as a process. We base our findings in a theoretical model, proposed by Elwyn et al, that highlights the distinction between deliberation and decision-making, and propose modifications to this model specific to knee replacement decision-making. This study used two focus groups of six patients each and in-depth interviews with 10 patients to examine the factors that affect patient decision-making and their interaction at different points in the decision-making process. A qualitative analysis of themes, based on a constant comparative method, is used to analyse the data. This study was approved by the Dyfed Powys Research Ethics Committee (13/WA/0140).Background
Methods
Total Knee Replacement (TKR) is an effective treatment for knee arthritis. One long held principle of TKRs is positioning the components in alignment with the mechanical axis to restore the overall limb alignment to 180 ± 3 degrees. However, this view has been challenged recently. Given the high number of replacements performed, clarity on this integral aspect is necessary. Our objective was to investigate the association between malalignment and outcome (both PROMs and revision) following primary TKR. A systematic review of MEDLINE, CINHAL, and EMBASE was carried out to identify studies published from 2000 onwards. The study protocol including search strategy can be found on the PROSPERO database for systematic reviews.Background
Metod
A patient-centred approach, usually achieved through shared decision
making, has the potential to help improve decision making around
knee arthroplasty surgery. However, such an approach requires an
understanding of the factors involved in patient decision making.
This review’s objective is to systematically examine the qualitative literature
surrounding patients’ decision making in knee arthroplasty. A systematic literature review using Medline and Embase was conducted
to identify qualitative studies that examined patients’ decision
making around knee arthroplasty. An aggregated account of what is
known about patients’ decision making in knee arthroplasties is
provided.Objectives
Methods
There is an ever increasing demand for Randomised Controlled Trials (RCTs) in Trauma and Orthopaedic Surgery. Patient recruitment is often challenging. Among other factors, individual surgeon's preference is often quoted as a major obstacle. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution, but could not help in everyday running of a trial. We wanted to develop a new trial eligibility assessment tool using the Collective Equipoise Principle. We developed an online system that quantifies collective uncertainty among a group of surgeons for an individual clinical case in real time. This data was collected for patients in the UK Heel Fracture Trial (UK HeFT) as an independent research project. Both patients who agreed or not to take part in the trial were approached in six weeks follow up clinic to avoid interference with clinical course. For those who agreed, anonymous clinical data together with images (Xrays and CT) was published on a secure on line forum and registered surgeons were alerted via email and SMS. Surgeons submitted their opinion instantly via specially designed interactive voting scale. 80:20 ethical uncertainty distribution limit was applied using Subjective Logic to calculate an Uncertainty Index (UnIx) for every patient. This approach was evaluated as an eligibility assessment tool for RCTs.Introduction
Methods
Simulation is increasingly perceived as an important component of surgical training. Cadaveric simulation offers an experience that can closely simulate operating on a living patient. We have explored the feasibility of providing cadaveric training for the whole curriculum for trauma and orthopaedic surgery speciality trainees, before they perform those operations on living patients. An eight station surgical training centre was designed and built adjacent to the mortuary of a University Hospital. Seven two-day courses for foot and ankle, knee, hip, spine, shoulder and elbow, hand and wrist, and trauma surgery were designed and delivered. These courses, designed for 16 trainees, were delivered by eight consultant trainers and a course director. Each was structured to allow every trainee to perform each standard operation in the curriculum for that respective subspecialty. We designed the courses to maximise simulated operating time for the trainees and to minimise cost. We surveyed trainers and trainees after the courses to qualitatively assess their value.Introduction
Methods
There is an ever increasing demand for quality clinical trials in surgery. Surgeons' co-operation and enthusiasm to participate are important, if not crucial in success of such studies, especially if they are multi-centred. Clinician's individual uncertainty (equipoise) about a case has been often cited as an ethical basis for inviting a patient to take part in a clinical trial. This study aims to establish current attitudes of surgeons participating in a national multi-centred randomised controlled trial and explores an on line tool for instant assessment of collective uncertainty (equipoise) for individual clinical cases eligible for a trial. Surgeons taking part in the UK Heel Fracture Trial were invited to take part. If agreed, they were asked to evaluate treatment prognosis for eligible for the trial anonymised cases of calcaneal fractures online by means of specially designed system. The cases were published on a password protected website on ad-hoc basis during the three years course of the trial. Their responses were submitted instantly on line.Study aim
Study design
Cam-type femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in young adults. It is likely that it is a cause of early hip degeneration. Ganz et al have developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic osteochondroplasty to reshape the proximal femur and relieve impingement. Fifty patients who presented with mechanical hip symptoms and had demonstrable cam-type FAI on radially-reconstructed MR arthrography, were treated by arthroscopic osteochondroplasty. Ten patients had a post-operative CT; from these images flexion and internal rotation range was tested in a virtual reality (VR) model to determine adequacy of resection. All patients were followed up for a minimum of one year, and post-operative Non-Arthritic Hip Scores (NAHS, maximum possible score 100) compared with pre-operative NAHS.Background
Methods
Femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in sportspersons. In femoro-acetabular impingement abnormal contact occurs between the proximal femur and the acetabular rim during terminal motion of the hip as a result of abnormal morphologic features involving the proximal femur (CAM) or the acetabulum (Pincer) or both (Mixed) leading to lesions of acetabular labrum and the adjacent acetabular cartilage. It is likely that it is a cause of early hip degeneration. Ganz developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic technique to reshape the proximal femur and remove prominent antero-superior acetabular rim thereby relieving impingement. Twelve patients presented with mechanical hip symptoms and had demonstrable cam-type (eight patients) or mixed (four patients) FAI on radially-reconstructed MR arthrography, were treated by arthroscopic femoral osteochondroplasty and acetabular rim resection if indicated. All patients were competing at the highest level in their respective sport (football, rugby and athletics). All patients were followed up and post-operative Non-Arthritic Hip Scores (NAHS, maximum possible score 100) compared with pre-operative NAHS.Background
Methods
We investigated the blood flow to the femoral head during and after Resurfacing Arthroplasty of the hip. In a previous study, we recorded the intra-operative blood flow in 12 patients who had a posterior approach to the hip and 12 who had a trochanteric flip approach. Using a LASER Doppler flowmeter, we found a 40% drop in blood flow in the posterior group and an 11% drop in the trochanteric flip group (p<0.001). The aim of this current study was to find out whether the intra-operative fall in blood flow persists during the post-operative period. We therefore conducted a Single Positron Emission Tomography (SPECT) scan on 14 of the same group of patients. The proximal femur was divided into four regions of interest. These were the mid-shaft, proximal shaft, inter-trochanteric and head-neck regions. The data was analysed for bone activity and comparisons made between the two groups for each region of the femur. We found that the bone activity in the mid-shaft, upper-shaft, and head-neck regions was the same eleven months after the surgery irrespective of the approach to the hip. However there was higher activity in the trochanteric flip group in the inter-trochanteric region. We conclude that the intra-operative deficit in blood flow to the head-neck region of the hip associated with the posterior approach does not seem to persist in the late post-operative period. We believe the reason for increased bone activity in inter-trochanteric region to be due to the healing of the trochanteric flip osteotomy.
The aim of this study was to assess the risks and benefits of mini-incision TKR. The limited exposure afforded by the small skin incision in the new technique of mini-incision TKR has the potential for increasing the risk of mal-positioning of components. Minor mal-positioning of components has the potential to increase polyethylene wear and may lead to early loosening and poor functioning of the TKR. The literature supports the concept that alignment within +/- 3 degrees of neutral mechanical alignment in the coronal plane is associated with a better outcome. If the mechanical axis falls outside this range it may have up to a 30% failure rate at 10 years. We report the results of 166 mini-incision TKR that have been undertaken in 154 patients (96F; 58M; mean age 72; mean BMI 29; 96% OA) since November 2003. The pre-operative mechanical axis ranged from 8 degrees valgus to 15 degrees varus. Surgery was undertaken with a precise skin incision and a midvastus split approach. Specialised cutting blocks were used to facilitate a smaller incision. The prosthesis inserted was a cemented Zimmer NexGen TKR of either posterior stabilised or cruciate retaining form. Long leg weight bearing alignment radiographs were available in 52% of patients. The mechanical axis was measured in the coronal plane and found to lie within +/- 3 degrees of neutral in 86% of patients. This compares favourably with the current literature which reports the mechanical axis falling within this range in between 72% and 85% of cases. We believe the mini-incision TKR is a safe, reliable and reproducible technique offering substantial savings to the patient and health service without compromising accuracy.
Several factors have been identified that may affect outcome after total knee replacement (TKR). We performed a systematic review of studies that looked at the association of pre-operative factors and outcome after primary total knee replacement for osteoarthritis. All study types that investigated TKR for osteoarthritis were considered except retrospective case-series. Studies that included patients undergoing revision TKR were excluded if they did not provide separate results for primary and revision knee replacement. Any patient factor that was measured in the pre-operative period was included. The factors measured included age, sex, race, income, body mass index (BMI), medical or joint co-morbidity, level of education, disease specific scores and their subcategories and general health scores. Studies that recorded outcome measures were only included if evidence of validation for use after total knee replacement was available. We identified 590 studies purporting to evaluate TKR for OA. Of these, 25 studies were retrieved for in-depth consideration and 10 were found to meet the inclusion criteria. Most of these were cohort studies that used some form of regression analysis. The results showed that the strongest and most consistent correlations were between pre-operative pain scores, pre-operative function scores, co-morbidity and post-operative function scores. Age, gender and level of education were not significant predictors of outcome. However, even the best models could only predict 36% of the variance in outcome. Understanding which factors influence outcome the most will be of great benefit to patients and those who plan and deliver healthcare.
We used a laser Doppler flow-meter with high energy (20 m W) laser (Moor Instruments Ltd. Milwey, UK) to measure the blood flow to the femoral head during resurfacing arthroplasty. Twenty-four hips were studied; 12 underwent a posterior approach and twelve a Ganz's trochanteric flip osteotomy. The approach was determined according to surgeon preference. Three patients were excluded, The exclusion criteria were previous hip surgery, history of hip fracture and avascular necrosis (AVN). All patients had the hybrid implant with cemented femoral component. During surgery a 2.0mm drill bit was passed via the lateral femoral cortex to the superior part of the head neck junction. The position was confirmed using fluoroscopy. The measurements were taken during five stages of the operation: when the fascia lata was opened (baseline), at the end of soft tissue dissection, following dislocation of the hip, after relocation back into the socket, after inserting the implants prior to closing the soft tissues and, finally, at the end of soft tissue closure. The results were analysed and the values were normalised to a percentage of the baseline value. We found a mean drop of 38.6 % in the blood flow during the posterior approach and a drop of 10.34% with the trochanteric flip approach. The significant drop occured between the baseline (1st stage) and the end of the soft-tissue dissection (2nd stage). In both groups the blood flow remained relatively constant afterwards. Our study shows that there is a highly significant drop in blood flow (p<0.001) during the posterior approach compared with the trochanteric flip approach.
Thromboprophylaxis remains a controversial issue and many disagree about the optimum method or even if it is required at all. We present a new method of performing meta-analysis incorporating studies with both experimental and observational study designs. We have developed a model that compares study cohorts of several different methods of thromboprophylaxis with a simulated matched control group whose variance helps to adjust for bias. This allows meaningful comparisons between studies and treatments that have not been directly compared. We performed a systematic review of the literature from 1981 to October 2004. Studies where more than one method of prophylaxis was used were excluded from analysis. For each individual method of prophylaxis, data was extracted, combined and converted to give estimates of the rates of symptomatic, proximal DVT, fatal PE and major bleeding events. We identified 1242 studies of which 203 met the inclusion criteria for further analysis. This represented the results of over fifty thousand studied patients. We expressed the results for the different prophylactic methods as odds ratios compared to no prophylaxis. All methods showed a beneficial effect in reducing VTEs apart from stockings and aspirin which showed an increase in the number of PE events. These results are particularly interesting when viewed from the standpoint of an individual NHS hospital trust that performs around 500 hip and knee replacements per year. Over a 5 year period, the more effective methods of prophylaxis prevented between 15 and 40 symptomatic DVTs and up to 3 fatal PEs compared to no treatment. However, they cause between 8 and 40 more major bleeding events. We do not know the proportion of these major bleeding events that are fatal.
A two sample t-test demonstrated cobalt and chromium ion levels were significantly higher in patients with abnormalities on USS (p=0.038, p=0.05 respectively), patients with normal USS were more likely to have a retroverted femoral component (p=0.01).
Our aims were to design a novel scale marker which does not require such precise positioning, and to compare the accuracy of this new marker with a standard single ball marker.
The posterior marker consists of a 75x75cm square foam mat, incorporating multiple 25.4mm metal rods arranged in series down the centre. The anterior marker is made from five 25.4mm steel balls, linked in series at 20mm intervals. The mat is positioned just underneath the patient’s pelvis as they lie supine for their radiograph. The five balls are placed in the midline over the patient’s suprapubic region, and the x-ray is then taken. The radiographic dimensions of the ball and rod which are located between the hips are then measured. The magnification of the hips may then be calculated from these dimensions using a simple equation. To validate the new “double” marker, it was compared with a conventional single marker ball. 74 hip arthroplasty patients undergoing routine radiographic follow up were recruited. Both the new double marker and the single marker were applied at the time of x-ray, the magnification according to each was calculated, and these were compared to the true radiographic magnification as determined from the known dimensions of the prosthesis. All markers were positioned by independent radiographers trained in their use.
The acetabular surface is divided radially into five zones (A, B, C, D, E) starting postero-inferior (A) and ending antero-inferior (E). Each zone is further divided in half into an outer and inner zone, forming ten zones in total i.e Ai, Ao, Bi, Bo.etc. This study was performed during therapeutic hip arthroscopy of 41 patients. Five surgeons took part in the study. After gaining access into the hip joint one of the surgeons identified three small intra-articular features (marks, small defects or blood clots) as X, Y and Z to some or all of the other 4 surgeons. Each of the other surgeons examined the hip independently without Discussion: and recorded the location on a hip map. If two surgeons had observed a point, this provided one pair to assess agreement; three or four surgeons provided three or six pairs respectively. Each observation of a point by a pair of surgeons (a point-pair) provided one opportunity for assessment of agreement.
All surgeons reported that they found the system easy to use. There was no difference in the level of disagreement between more and less experienced surgeons or a learning effect with time.
Randomised controlled clinical trials (RCTs) produce the most reliable evidence about the effects of clinical care. In surgical trials, lack of surgeons’ individual equipoise (state of genuine uncertainty about treatment arms) appears to be one of the greatest obstacles. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution (Freedman, 1987), but could be applied only at the beginning of a trial to a general trial question. We developed a system that quantifies collective uncertainty among a group of surgeons for an individual clinical case. After a successful pilot study the system was introduced as an independent project within the UK Heel Fracture Trial. The expert panel included 10 surgeons from 8 hospitals. Anonymous clinical data of potentially eligible consecutive cases including CT and X-ray images was published on a secure online forum after 6 weeks follow up clinic to avoid interference with clinical course. Surgeons registered in the panel estimated the probability that the patient would be better or worse by various degrees with operative treatment. 30 clinical cases have been analysed, including 6 bilateral fractures (otherwise excluded). 86.7% could be recommended for inclusion in the trial, compared to 43.3% recruited out of this series in the actual trial. Lack of individual uncertainty within the panel was present in every case. The system not only has a potential to improve recruitment in surgical RCTs, but provides ethically sound grounds to offer or otherwise a patient participation in a trial. Surgeon’s individual equipoise dilemma and responsibility is shared with colleagues. Cases that otherwise will be excluded can be evaluated with broader inclusion criteria. The system is easy to use, cheap and reliable. Limitations include surgeons’ compliance and time lapse (at least 48 hours) for voting to be completed.
The amount of bone formed under each condition was assessed by solubilising the mineral content in hydrochloric acid overnight and then measuring the change in colour induced by Calcium exposed to a commercial reagent. The amount of calcium detected was then determined using a standard curve. This experiment was repeated in cells from 3 patients.
There was a statistically significant impairment in osteogenesis at a concentration of tobramycin of 400 microg/ml and above.
Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good. The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome. The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded. Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient. 58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p<
.003) In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.
We applied the technique of path analysis to investigate the effect of potential prognostic factors, including injury characteristics and treatment choices, on the risk of delayed healing or non-union after operative treatment of tibial shaft fractures. Data were collected in a prospective observational study of 41 Swiss hospitals over two years, and analysed by regression models and path analysis. Path analysis is a technique to visualize the most important associations between clinical factors and outcome in a ‘causal path diagram’ that summarises the most likely cause and effect relationships. Factors having a direct relationship with the occurrence of delayed healing or non-union included open fracture (RR 6.7), distal shaft location (RR 2.2), and initial treatment with an external fixator (RR 2.8). There were many other significant inter-relationships within the final diagram. For example, the choice of treatment was related to factors such as fracture aetiology, AO classification, location and skin injury. Fracture classification was not associated with delayed healing and non-union after adjustment for other factors including treatment choice. The association of hypothesised risk factors, such as soft tissue injury and fracture location, with delayed healing or non-union was confirmed and measured. This study suggested that the use of an external fixator had a direct, negative effect on outcome, and that the use of nails or plates might contribute to delayed healing or non-union by their association with post-operative diastasis. These observations support this first use of path analysis in orthopaedics as a powerful technique to interpret data from an observational study.
To assess whether epidural steroid injection [ESI] is effective in the treatment of nerve root pathology caused by compression in the lumbar spine secondary to either spinal stenosis or disc prolapse, we carried out a prospective randomised controlled trial; patients were randomised either to ESI or Intramuscular steroid injection, with minimum two year follow-up. Ninety two patients with symptoms, signs and radiological findings consistent with lumbar nerve root compression suitable for surgical decompression. The main outcome measures were the Oxford Pain Chart over the first month, Oswestry Disability Index, and the need for surgery. There was a significant reduction in pain early on after ESI compared with controls [p=<
0.004] between 10 and 35 days. There was no difference in the long term between the two groups and the rate of surgery in the two groups was not significantly different. Indeed the rate of surgery was higher in the ESI group than the control group [41% vs.31%] but this was not significant. A second ESI did not change the likelihood that surgery would be required.
Hip and knee arthroplasty has been associated with relatively high rates of thromboembolic events and the majority of UK orthopaedic surgeons use at least one form of prophylaxis. Of the many different subgroups of thromboembolic rates that are commonly presented in the literature, symptomatic proximal deep vein thrombosis (spDVT) and fatal pulmonary embolism (fPE) are perhaps the most important clinical outcomes. To determine the effectiveness of common chemical and mechanical prophylactic methods in preventing spDVT and fPE in patients undergoing primary hip and knee arthroplasty. A systematic review of the literature from 1981 to December 2002 was performed. Predetermined inclusion and exclusion criteria were applied. Studies where more than one method of prophylaxis was used were excluded from analysis. For each individual method of prophylaxis, data was extracted, combined and converted to give estimates of the rates of spDVT, fPE and major bleeding events. Absolute risk reduction estimates for spDVT, fPE and major bleeding events were calculated by comparing the thromboembolic rates for each method of prophylaxis with using no prophylaxis of any kind. 992 studies were identified of which 162 met the inclusion criteria. No method of prophylaxis was statistically significantly more effective at preventing spDVT and fPE than using nothing. There were at least as many major bleeding complications as spDVTs. The number of fPEs prevented was very small. When complications such as major bleeding are considered, the evidence behind the use of any prophylaxis is unconvincing.
Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84). Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179). Recurrent instability (subluxation /dislocation) following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05] Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of recurrent instability was 70% (119/170). Recurrent instability following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p<
0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24].
A non-evaluative culture; Misunderstanding of the scientific basis of trial design; Lack of individual equipoise; The complexity of the relationship between patient and surgeon; Inadequate measures of outcome; Practical problems associated with long follow-up, clinical work load and lack of funding.
Rheumatoid arthritis results in pain and loss of function due to gradual destruction of articular cartilage. The shoulder joint is frequently involved and a prosthetic replacement of the humeral head can restore function and relieve pain. Deficiency of the rotator cuff is common in patients with rheumatoid arthritis. Longevity of movement at the intraprosthetic interface of the bipolar shoulder prosthesis is debatable and has not previously been studied in rheumatoid arthritis. We report a radiological study of the intraprosthetic movements of a bipolar shoulder replacement in 25 shoulders in 20 patients with rheumatoid arthritis of mean age 66 years (SD 10 years). Shoulders were X-rayed at a minimum of 3 and a maximum of 10 years from surgery. Measurements were repeated in 12 shoulders 3 years later. The patient was positioned in the scapular plane. An initial X-ray was taken with the arm in neutral and a further X-ray taken with the arm in full active abduction. Measurements were taken to determine the movement at the intraprosthetic interface and at the prosthesis/glenoid interface. Interobserver error and intraobserver error were determined using an intraclass correlation coefficient (ICC). A paired T-test and Pearson Correlation Coefficient were used to compare intraprosthetic movement with prosthesis/glenoid movement. We found that intraprosthetic movement was preserved up to 10 years from surgery. However, there was no significant difference between intraprosthetic movement and shell/glenoid movement, with some shoulders exhibiting paradoxical movement at the intraprosthetic interface. Repeating the measurements after a 3 year interval in a subgroup of 12 shoulders showed a significant difference in intraprosthetic movement. Interobserver and intraobserver reliability for measurements of the movement at the intraprosthetic interface were excellent with a We conclude that movement of the bipolar shoulder prosthesis in rheumatoid shoulders at the intraprosthetic interface is preserved up to 10 years from operation but is not related to or significantly different from prosthesis/glenoid movement and requires further investigation.