Triple-tapered cemented stems were developed in the hope that they would reduce aseptic loosening and prevent calcar bone loss.

Between March 2005 and April 2008, a consecutive series of 415 primary C-stem AMT hip arthroplasties in 386 patients were performed under the care of three surgeons at our institution. When all the patients had reached the 5-year anniversary of surgery, functional questionnaires were sent out by mail. In the event of non-response, reminders were sent by post before the patients were contacted by telephone. Postoperative radiographs were also reviewed.

Follow-up ranges from 60 to 99 months, with a mean of 76 months. 32 hips (8%) were lost to follow-up. The median OHS was 40, median SF-12 mental component score (MCS) was 50, and median SF-12 physical component score (PCS) was 39. Radiographic review showed that aseptic femoral component loosening has yet to be observed. At 99 months follow up, stem survivorship is 96.9% (95% confidence interval (CI) 82.5 to 99.5). Adverse events such as calcar fracture, greater trochanter fracture and dislocation were rare at <1%.

The C-stem AMT demonstrates excellent implant survivorship at 5–8 year follow-up, as well as good midterm functional outcome.

We compared the early complication rates of total hip (THA) and total knee (TKA) arthroplasty carried out at a regional orthopaedic hospital (AOC) and two Independent Sector Treatment Units (ISTUs) (WGH and CNH). After THA, reoperation rates were higher at CNH (9%) than AOC (0.6%) or WGH (1.4%). After TKA, reoperation rates at CNH were (8%) higher than AOC (1%) and WGH (1.9%).

5% of patients undergoing TKR at CNH underwent 2 stage revision for deep infection.

After THA, dislocation rates at CNH (6%) were higher than AOC and WGH (1.8%). Readmission from CNH (13%) was higher than AOC (1.2%) and WGH (0.6%).

Major wound problems at CNH (20%) were higher than WGH (3.8%) and AOC (0.4%).

After TKA, major wound problems were higher at CNH (19%) compared to WGH (1.9%) and AOC (1.1%). Readmission rates not requiring surgery from CNH (13%) were higher than AOC. (1.1%) and WGH (1%). AOC and WGH audited their outcomes. None were available from CNH. WGH initially missed many of their complications because they presented at base hospitals elsewhere.

ISTUs performed approximately 2/3rds of procedures for which patients had been referred from base hospitals.

At CNH, 23% were rejected on grounds of potential co-morbidity. Audit from ISTUs is inferior to NHS hospitals and the results in one of those audited significantly worse.

Patients offered surgery at ISTUs should be told that the audited outcome of the surgeon who will be treating them is not known and that, in some, results are inferior to surgery in the NHS.

Metal-on-metal resurfacing offers an alternative strategy to hip replacement in the young active patient with severe osteoarthritis of the hip. The aim of this study was to compare functional outcomes, failure rates and impending revisions in hybrid total hip arthroplasties (THAs) and Birmingham Hip Resurfacings (BHRs) in young active patients.

We compared the 5-7 year clinical and radiological results of the metal-on-metal BHR with hybrid THA in two groups of 54 hips each, matched for sex, age, body mass index and activity. Function was excellent in both groups as measured by the Oxford hip score (median 13 in the BHRs and 14 in the THAs, p=0.14), but the resurfacings had higher UCLA activity scores (median 9 v 7, p=0.001) and better EuroQol quality of life scores (0.90 v 0.78, p=0.003). The THAs had a revision or intention to revise rate of 8% and the BHRs 6%. Both groups demonstrated impending failure on surrogate end-points. 12% of THAs had polyethylene wear and osteolysis under observation, and there was femoral component migration in 8% of resurfacings. Polyethylene wear was present in 48% of hybrid hips without osteolysis. Of the femoral components in the resurfacing group which had not migrated, 66% had radiological changes of unknown significance (classification proposed).

In conclusion, the early to mid-term results of resurfacing with the BHR appear at least as good as those of hybrid THA. Only by longer term follow-up will we establish whether the change of practice recorded here represents a true advance.

Introduction: We compared the eight- to ten-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing (BHR) with a hybrid total hip arthroplasty (HYBRID) in two groups of 54 hips, previously matched for gender, age, body mass index and activity level.

Method: Patients were followed up in outpatients and function assessed by using the Oxford Hip Score, UCLA activity score and Euroqol score. Radiographs were assessed for osteolysis and wear. BHR were also assessed for the presence of a pedestal sign around the femoral component.

Results: The mean follow up of the BHR group was 9 years (8.17 to 10.33) and for hybrids 10 (7.53 to 14.5). Four patients had died in the hybrid group and one in the BHR. Four were lost to follow up in each group. The revision rate in the BHR group was 9.25% verses 18% in the Hybrid, a further eight patients in the hybrid group have evidence of wear and osteolysis and are intended for revision (p=0.008). One patient in the BHR group was explored for late onset sciatic nerve palsy. All patients in the hybrid group had evidence of polyethylene wear, mean 1.24mm (0.06–3.03). 90% of the BHR group had evidence of a pedestal sign.

Satisfactory function was shown in both groups. There was no significant difference between groups with respect to the OHS but the UCLA score was superior in the BHR group (p=0.008). There was no significant difference for Euroqol visual analogue score. 56% of hybrids were delighted with their hip replacement verses 65% of BHR patients.

Discussion: After ten years the hip resurfacing patients were still more active and had a lower revision burden than the hybrid hip replacements. Both groups showed worrying radiological evidence of change with long-term follow-up.

Metal-on-metal resurfacing offers an alternative strategy to hip replacement in the young active patient with severe osteoarthritis of the hip. The functional outcomes, failure rates and impending revisions in hybrid total hip arthroplasties (THAs) and Birmingham hip resurfacings (BHRs) were compared after 5–7 years. We studied the clinical and radiological results of the BHR with THA in two groups of 54 hips each, matched for sex, age, BMI and activity.

Function was excellent in both groups as measured by the Oxford hip score (median 13 in the BHRs and 14 in the THAs, p=0.14), but the resurfacings had higher UCLA activity scores (median 9 v 7, p=0.001) and better EuroQol quality of life scores (0.90 v 0.78, p=0.003).

The THAs had a revision or intention to revise rate of 8% and the BHRs 6%. Both groups demonstrated impending failure on surrogate end-points. 12% of THAs had polyethylene wear and osteolysis and there was femoral component migration in 8% of resurfacings. Polyethylene wear was present in 48% of hybrid hips without osteolysis. Of the femoral components in the resurfacing group which had not migrated, 66% had radiological changes of unknown significance.

In conclusion, the early to mid-term results of resurfacing with the BHR appear at least as good as those of hybrid THA.

Introduction: The results of metal-on-metal hip resurfacing (MOMHR) from inventing centres show excellent function with low revision rates in the short to intermediate term. This study investigated whether similar results could be achieved in an independent unit.

Methods: All cases of MOMHR were identified since its introduction in our centre in 1999, and cases with less than 18 months follow-up excluded. Outcome was assessed by Oxford Hip Score (OHS), and UCLA activity score. Complications and further surgery was recorded. Pre-, post-op and follow-up radiographs were reviewed.

Results: 358 resurfacings in 315 patients (238 Birmingham hip resurfacings and 120 Cormet 2000, 8 surgeons). 13 (3.6%) revisions: 4 early fractures, 6 osteonecrosis, 1 aseptic femoral loosening, 1 infection, 1 isolated cup revision. 2 died, 16 (4.7%) were lost to follow-up. Outcome was assessed in the remaining 327 hips at a mean 39 months (18–79). Median OHS 13, median UCLA score 8. 89% employed in moderately heavy or heavy occupational work pre-operatively were similarly employed at follow-up.

2 cups had migrated and 6 had lucent lines. 8 femoral components had migrated. 6 had focal osteolysis. 66% of hips had ‘pedestal’ signs around the stem of the femoral component (classification proposed).

Discussion: The functional outcomes achieved in this series match those from inventing centres, but the revision rate was higher. This is partly explained by early fractures which may be associated with poor case selection or technical errors early in a surgeon’s learning curve. Later failures, of which osteonecrosis is of particular interest, also occurred at a higher rate. Migration of the femoral component may represent impending failure and further work is required to define the aetiology and consequences of the pedestal signs noted.

Tibial fractures represent a heterogeneous group of fractures that are difficult to treat and vary widely in their time to union. Judging when it is safe to remove an external fixator or plaster cast requires clinical and radiological assessments both of which are subjective. Any errors in determining when a fracture has healed can lead to a prolonged treatment time or to refracture. Many methods have been employed to attempt to define clinical union in an objective manner including ultrasound, DEXA scanning, vibration analysis, and fracture stiffness measurements. Stiffness measurements are however time consuming to perform, of debatable clinical significance, and applicable only to fractures treated with external fixators. It has been previously observed^1,2 that weight bearing increases with time post-fracture. It has also been suggested³ that the ability of a patient to weight bear on the fractured limb is controlled by a biofeedback mechanism of biological self-control of fracture site strain that will be related to the stiffness of the fracture. We hypothesised that weight-bearing will be closely related to fracture healing and could be used as an alternative measure of healing where other objective measures of healing are not available or are impracticable.

A group of ten patients with tibial fractures treated by external fixation were studied. Using a Kistler force plate set into the floor, ground reaction forces for both lower limbs (fractured and non-fractured) were measured during normal walking at three weekly intervals. Concurrent fracture stiffness measurements were made using the Orthofix Orthometer.

In 8 patients who made good recoveries, the fixator was removed between 15–20 weeks post injury when the fracture stiffness had reached a minimum of 15 Nm/deg. Weight-bearing through the injured leg was seen to approach 90% of that through the uninjured leg in the 3 weeks prior to fixator removal. Two patients with delayed union achieved weight bearing of less than 40% of normal between 15–20 weeks. They also demonstrated low values of fracture stiffness (< 5 Nm/deg.) and subsequently required operative intervention to achieve union.

In this small study of 10 patients, weight bearing appears to correlate well with clinical union. It is quicker and easier to assess than stiffness and potentially has relevance to other fixation methods. We are continuing these measurements on conservatively treated, intra-medullary nailed, and externally fixed tibial fractures.