Negative remodelling of the femoral cortex in the form of calcar resorption due to stress-shielding, and femoral cortical hypertrophy at the level of the tip of the implant due to distal load transfer, is frequenly noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapered components.

The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The implant is designed to subside within the femoral cement mantle utilising the cement property of creep, generating hoop stresses, which are transferred more proximally to the femoral bone, starting at the level of the medial calcar. The intention is to load the proximal femur minimising stress-shielding and calcar resorption, as well as reducing distal load transfer as signified by the lack of distal femoral cortical hypertrophy.

We present the results of a consecutive series of 500 total hip replacements using C-stem femoral components, performed between March 2000 and December 2005 at a single institution. Data was collected prospectively and all patients remain under annual follow-up by a Specialist Arthroplasty Practitioner. The operations were performed using a standard surgical technique with third generation cementing using Palacos-R antibiotic loaded cement.

500 arthroplasties were performed on 455 patients with an average age at the time of surgery of 68.3 years (23-92). There were 282 (62%) female and 173 (38%) male patients with osteoarthritis being the predominant diagnosis. 77 patients have died (73 hips) and the average duration of follow-up for the entire series is 81 months (52-124).

Only 2 femoral implants have been revised - one for deep sepsis and the other as part of a revision procedure for a loose acetabulum, although the femoral component itself was not loose. One implant is currently loose following a periprosthetic fracture treated by internal fixation, but none of the remaining implants demonstrates any progressive radiolucencies in any Gruen zones or any features suggestive of current or future loosening. Calcar rounding has been observed, but there have been no cases with obvious loss of calcar height and no cases of distal femoral cortical hypertrophy.

The C-stem femoral component has therefore performed well in clinical practice and the objective of eradicating negative bone remodelling has been achieved. The study is ongoing.

Objectives

The main objective of our study was to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined whether there was any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Cemented acetabular components continue to be used in more than half of the total hip replacements performed in the United Kingdom. The implants are relatively inexpensive but the results rely heavily on precise surgical technique, with restoration of the centre of rotation of the hip and the creation of an equal cement mantle with good pressurisation and penetration of the cement into the bone.

The Opera all polyethylene acetabular component was designed with a malleable flange, which could be independently pressurised, a long posterior wall to promote stability and instrumentation which ensured that pressurisation could be maintained throughout the curing process.

We present for the first time, the medium-term results of 409 consecutive cemented flanged Opera acetabular components performed in 374 patients.

247 operations were performed via a trochanteric osteotomy and 162 via a posterior approach, using multiple key holes, cement pressurisation and Palacos-R cement. Autograft was used in 32 cases.

Cemented femoral components were used in all cases. There were 241 Charnley stems with 22mm heads and 168 polished triple tapered C-stems (146 with 22mm heads and 22 with 26mm heads).

The average age at the time of surgery was 68.2 years (32–87) and the average duration of follow-up was 89 months (60–130). 54 patients (56 hips) died during the follow-up period.

The acetabulum was assessed using the zones of DeLee and Charnley, and the Hodgkinson classification.

There was one temporary femoral nerve palsy, two dislocations and 3 non-fatal pulmonary emboli.

Both components were revised in two hips for deep sepsis, and in two hips only the femoral implant was revised, one for a fractured stem and one for aseptic loosening, with the original acetabular components remaining in situ.

Of the remaining original acetabular components 6% have shown progressive radiological demarcation, none have migrated, but in two hips there is evidence of rapid wear and the development of osteolysis.

The use of polished femoral implants employing the taper-slip philosophy now dominates the cemented portion of the hip arthroplasty market in the United Kingdom. Despite this fact, there have been very few published or presented series reporting the medium to long-term results of double tapered implants and only one previously reported series looking at the results of the triple tapered stem.

We present the results of 500 consecutive polished triple tapered C-stem femoral components performed in 455 patients.

All operations were performed using a posterior appproach, with cemented all polyethylene acetabular components and the use of third generation femoral cementing techniques, restrictors, centralisers and Pala-cos-R cement.

There were 282 female patients (62%) and 173 males (38%). The average age at the time of surgery was 68.3 years (23 to 92), with an average duration of follow-up of 71 months (36 to 112). 47 patients (51 hips) died during the follow-up period at an average of 54 months (1–87).

There were 3 dislocations, 2 on one occasion and one twice, at an average of 4 years. There were 2 deep infections, one of which required revision, and 4 non-fatal pulmonary emboli. There were 3 undisplaced trochanteric cracks treated by cerclage wiring and 3 nerve palsies: 2 femoral (temporary) and one sciatic (permanent). There was only one case of significant heterotopic ossification (Brooker Class 4).

The stem was neutral in 89% of cases, varus in 7% and valgus in 4%. Subsidence within the cement mantle occurred in 79% of cases, with an average of 0.87mm. 9 stems subsided 2 to 4mm but all stopped at 2 years and there was no further subsidence thereafter.

One hip was revised for deep infection but none of the remaining implants demonstrated any progressive radiolucencies in any Gruen zones and none demonstrated any features suggestive of current or future loosening. There was no evidence of negative bone remodelling.

The data was collected prospectively and the study is ongoing.

Objectives: To determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. Secondary investigations were on the requirement for subsequent interventions such as root blocks and/or surgery. A sub group analysis between sciatica and stenosis was undertaken.

Study Design: A randomised, double blind controlled trial.

Subjects: 150 eligible patients with radicular pain and unilateral chronic symptoms were randomised for a single injection with bupivacaine and methylprednisolone (b+s) or bupivacaine (b) alone.

Outcome measures: The outcome measures included the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg pain and back pain and patient’s subjective level of satisfaction of the outcome.

Results: 76 patients in the b only group and 74 patients in the b+s group.

Clinically useful improvements of greater than 10 points on the ODI occurred in 54%, deterioration of 10 points or more occurred in 17%. Visual analogue for leg improved by 2 or more in 63%.

There was no statistically significant difference between the groups at 3 months (change in ODI [p=0.2], change in VAS [back pain, p=0.28; leg pain, p=0.67]. Subgroup analysis revealed no statistically significant difference in the change in scores between the stenotic group and disc herniation group at 3 months. At 1 year follow-up data was available for 86% of the patients. There was no statistically significant difference in the rate of further interventions.

Conclusion: Clinical improvement occurs in both groups of patients. Corticosteroids did not provide additional benefit. There is no difference in the need for further root blocks or surgery.

We present the results of the polished triple tapered C-stem femoral component.

Prospective data was collected on a consecutive single surgeon series of 326 hip replacements in 293 patients performed between 2000 and 2005. All operations were performed via the posterior approach with a cemented all polyethylene acetabular component and third generation cementing of the femoral component.

There were 169 (58%) female patients and 124 (42%) males. There were 111 (34%) left sided procedures, 149 (46%) right sided and 33 bilateral (10%). Average age at time of surgery was 66.3yrs (25 – 89), with an average duration of follow-up of 50 months (12 – 78). The majority of the replacements were for osteoarthritis (271 hips 83%).

Nine patients (10 hips) died during the follow-up period at an average of 36 months (18 – 52), but outcome data was available on all patients and none were lost to follow-up. There was 1 temporary femoral nerve palsy, 2 non-fatal pulmonary emboli and 3 undisplaced trochanteric fractures. There were no dislocations, fatal pulmonary emboli, deep infections or revisions for any reason.

The stem was neutral in 90%, varus in 8% and valgus in 2%. There were no progressive radiolucencies in any Gruen zones and no distal femoral cortical hypertrophy. The average subsidence was 0.83mm, with none in 21%, < 0.5mm in 28%, 0.5 – 1mm in 41%, 1 – 2mm in 8% and 2 – 4mm in 2%.

There were no revisions and no stems demonstrated any features suggestive of current or future loosening. The study and prospective data collection is ongoing.

Study Design: A randomized, double blind controlled trial.

Objectives: Various studies have examined the therapeutic value of peri-radicular infiltration using treatment agents consisting of local anaesthetic and corticosteroids for radicular pain. The main objective is to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.

Subjects: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomised for a single injection with bupivicaine and methylprednisolone (b+s) or bupivicaine (b) only.

Outcome measures: Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for back pain and leg pain, claudication walking distance and patient’s subjective level of satisfaction of the outcome.

Results: We recruited 43 patients in the b+s group and 43 patients in the b only group. The follow up rate is 100%. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the ODI [p=0.7], change in VAS [back pain, p=0.68; leg pain, p=0.94], change in walking distance [p=0.7]). No statistical difference in the change in VAS score between stenotic group and disc herniation group at 3 months. Further subgroup analysis also showed no difference in the outcome between contained and non-contained herniation group.

Conclusion: Clinical improvement occurs in both groups of patients. Corticosteroid did not provide additional benefit.

Objectives: To assess whether peri-radicular infiltration of corticosteroids has any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Study Design: A double blinded randomised controlled trial

Methods: 81 patients with unilateral radicular pain and failed conservative management were randomised to two groups (B and S). Group B received a single peri-radicular injection with bupivacaine and group S received bupivacaine and methylprednisolone. Both patient and surgeon were blinded to the method of treatment. Statistical analysis involved the use of a Chi Square test.

Outcome measures: 1. Number of additional root blocks required and 2. Requirement for surgery.

Results: At a median follow-up of 20 months (range 12–31 months) follow-up data was available for 70 patients (86%) with 35 patients in each group. There were an equal number of males and females in the groups. In group B, 10 patients required a further root block (29%) compared with 6 patients in group S (17%) [p=0.39]. Similarly 8 patients in group B required subsequent surgery (23%) compared with 3 in group S (9%) [p=0.19]. These differences did not achieve statistical significance probably due to the modest size of this study.

Conclusion: Our findings suggest that adding corticosteroid to bupivacaine nerve root blocks may reduce the need for further root blocks and surgery.

Study Design: A randomised, double-blind controlled trial.

Objectives: To determine the efficacy of corticosteroids in periradicular infiltration for radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.

Summary of background data: Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anaesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomised trial to determine the efficacy of single injection of corticosteroids.

Methods: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomised for single double-blind injection with bupivicaine and methylprednisolone (b+s) or bupivicaine (b) only. Outcome measures include change in Oswestry Disability Index (ODI), change in Visual Analogue Score for back pain and leg pain (VAS), change in walking distance and patient’s subjective level of satisfaction of the outcome. Objective successful clinical outcome is defined as a change in 10% of ODI.

Results: We recruited 37 patients in the b+s group and 38 patients in the b only group. The follow up rate is 100%. 4 patients had early termination of the trial for discectomy and further rootblock. There is no statistically significant difference in the outcome measure between the groups at 3 months (change of the ODI [p=0.6], change in VAS [back pain, p=0.28, leg pain, p=0.95], change in walking distance [p=0.9]). 35% of patients in the b+s group and 55% in the b only group had a successful clinical outcome. Duration of symptoms has a statistically significant negative association with the change in ODI (p=0.03). No prognostic value is found in age, gender, pre-operative Modified Somatic Perception and Modified Zung Depression score.

Conclusion: Clinical improvement occurs in both groups of patients. However, corticosteroids do not provide additional benefit.

Purposes of Study and Background: To survey beliefs and attitudes about the management of mechanical back pain in General Practitioners (GPs) in two cities in the East Midlands, and to compare the findings with a similar recent Australian study. We also conducted a ‘found experiment’ on the use of ‘The Back Book’ by the GPs in the two cities following the purchase and distribution of its copies to the GPs in Leicester by the local Primary Care Trusts.

There has been a paradigm shift in the management of mechanical low back pain in the last ten years. Several different clinical guidelines are available based on current evidence in the literature. There is little to show how far these guidelines are being implemented. There are no studies of the barriers to implementation in the British population.

Methods and Results: A postal questionnaire consisting of ten questions, eight of which were taken from a questionnaire used in a similar survey from Australia. Two additional questions relating to the ‘Back Book’ were included. 164 GPs in the city of Leicester and 353 in the city of Nottingham were surveyed in August – September 2001.

The response rate was 70.1% (115) from Leicester and 65.7% (232) from Nottingham. The majority of GPs from both cities were aware of the current concepts about the management of mechanical back pain. The awareness and usage of “The Back Book” was significantly better amongst the GPs in Leicester (p < 0.001).

Conclusion: General practitioners in two cities in Trent region are well aware of current best practice in the management of acute back pain. Their attitudes and beliefs towards back pain management compared well if not better in some aspects, with those of their Australian counterparts. If the resource of ‘The Back Book’ is made available then GPs will use it, in keeping with current best evidence.