Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

Clinical success of total knee arthroplasty is correlated with correct orientation of the components. Controversy remains in the orthopaedic community as to whether the intramedullary or extramedullary tibial alignment guide is more accurate in the tibial cut.

Is there any difference between intramedullary and extramedullary jigs to achieve better accuracy of the tibial components in total knee replacements?

A retrospective study done on 100 patients during the time period 2007 to 2010. The 100 knee replacements were done by the same surgeon, where 50 patients had the intramedullary tibial alignment guide and the other 50 had the extramedullary one. The tibiofemoral angle was measured pre-operatively as well as post operatively, the tibial alignment angle was measured post operatively then the results were statistically analysed using the SPSS.

There was no significant difference between both groups regarding the tibial alignment angles. Both techniques proved accurate in producing an acceptable post operative tibial component alignment angle. We recommend orthopaedic surgeons choose either technique knowing that accuracy levels are similar.

The debate between intramedullary and extramedullary tibial cutting jigs/guides/ devices continues and most orthopaedic surgeons will use their preferred technique and will continue to achieve good post operative results as we have found in our centre. Our study is rare due to the fact we have a single surgeon performing both techniques, therefore controlling for any surgical experience or operating technique differences.

Introduction: Trochanteric osteotomy provides excellent exposure to perform hip replacement surgery. In the UK, 5.9% of primary hip replacements are performed using an osteotomy. Trochanteric non union is one of the complications of this approach. The aim of this study was to investigate the role of release of posterior trochanteric soft tissue release on the incidence of trochanteric non-union.

Method: We present the results of 100 patients who underwent primary cemented total hip replacement at our centre using the biplanar, intracapsular osteotomy. Group A (50 patients) had received a posterior trochanteric soft tissue release as part of the approach and Group B (50 patients) had not. Patients were followed up clinically and radiologically.

Results: In group A the trochanteric non union rate was 12% and in group B 2% (p< 0.05). According to the Hodgkinson’s classification of trochaneric non-union, all the non-unions in group A were grade 3 (> 1.5 cm migration) and group B was grade 2 (< 1.5cm migration).

Discussion: The two different techniques were examined on cadaveric specimens and it was noted that the obturator externus tendon was consistently cut as a part of the posterior soft tissue release. We conclude that this important structure should not be released as part of this approach to hip replacement. Obturator externus is an important adductor of the trochanter and preserving it decreases the incidence of trochanteric non-union.

Introduction: Extensive bone loss associated with revision hip surgery is a significant orthopaedic challenge. Acetabular reconstruction with the use of impaction bone grafting and a cemented polyethylene cup is a reliable and durable technique in revision situations with cavitatory acetabular bone defects. Slooff et al. (1996) reported the use of cancellous graft alone. Brewster et al. (1999) morselised the whole femoral head after removal of articular cartilage. This paper asks, is it really necessary to use pure cancellous graft?

Methods: 42 acetabular revisions using impacted morselised bone graft without removal of articular cartilage and a cemented cup were studied retrospectively. The mean follow up was 2.6 years (1–5yrs). Clinical and radiographic assessment was made using the Oxford Hip score, Hodgkinson’s criteria (1988) for socket loosening and Gie classification (1993) for evaluation of allograft consolidation and remodelling.

Results: 40(95%) sockets were considered radiologically stable (Type 0, 1, 2 demarcations). 2(5%) sockets were radiologically loose (Type 3 demarcation). There was no socket migration in our series. 27(64%) cases showed good trabecular remodelling (grade 3). 12(29%) cases showed trabecular incorporation (grade 2). Only 3(7%) cases showed poor allograft incorporation (grade 1). Average pre operative Oxford hip score was 41 and postoperative hip score was 27. There have been no socket re-revisions (100% survival) at an average of 2.6 years.

Conclusion: Early radiological and clinical survival results with retaining articular cartilage of femoral head allograft are similar and comparable to other major studies for acetabular impaction bone grafting in revisions. Minimal loss of allograft mass is 40% in obtaining pure cancellous graft. When there is a limited supply and demand of allograft, saving up to 40 % of the material is a valuable and cost effective use of scarce resources.

Introduction: The purpose of this study was to review the results of revision total hip replacement, using cement, done by a single surgeon in a tertiary referral centre. 164 patients underwent revision hip surgery for aseptic loosening, infection or recurrent dislocation.

Methods: 95 patients had a one stage revision, 25 patients had two stage revisions and the remainder had either the stem or socket revised. 10 patients had application of a PLAD for recurrent dislocation. Structural and morselized bone grafting was carried out in patients with extensive bone loss. 46 patients had morselized impaction bone grafting to the acetabulum. The first hundred patients with revision of both components and minimum follow up of twelve months were reviewed. Patients were routinely followed up in the clinic and assessed using the Oxford Hip Score and Merle D’Abigne scores for pain, function and range of movements. Radiographs were assessed for any demarcation or loosening.

Results: The mean age at surgery was 69.99 years (36ys to 95yrs). The mean follow up was 25 months (12 to 60 months). There were 5 dislocations, 2 wound dehiscence, 3 DVT’s and 2 deep infections in the whole group. There were 2 dislocations, 2 DVT, 1 wound dehiscence and 1 infection in the study group. The preoperative scores were available for 83 patients and the average scores for pain, function and range of movements were 3.2, 2.8 and 1.6 respectively. The average scores at the latest follow up were 5.08, 4.2 and 4.0. The mean Oxford Hip scores were 26.65. X-rays showed no demarcation in the acetabulum in 88 patients and in the femur in 92 patients. The trochanter was united in 72 patients. In 13 patients the trochanter had migrated more than 1 cm.

Conclusion: Revision total hip replacement using cement has shown good results in the short term. Cemented revisions are safe, reliable and also cost effective.

Aim: To determine if it is possible to predict the pattern of socket failure from the first post-operative x-rays.

Methods: A retrospective review was performed of patients undergoing revision hip surgery for aseptic socket loosening. An assessment was made of the pattern of failure and socket migration. Operative details of bone defects and reconstructions required were noted.

Results: 55 patients were identified with an average age of 46.2 years at primary surgery. The average socket survival was 16.14 years. There was no association between the patient’s age or original diagnosis and the duration of socket survival.

Supero-medial migration was seen in 27 (49%) of cases, demarcation without migration was seen in 18 cases (33%) and supero-lateral migration was seen in 7 (13%) cases. There were 2 (4%) socket fatigue fractures due to wear. There was 1 (2%) patient with a worn socket and no loosening.

Reconstruction was achieved by impaction bone grafting alone in 25 cases, IBG and a block allograft in 9 cases, cement alone in 8 cases and IBG with a rim mesh in 4 cases.

In cases where the supero-lateral margin of the socket was covered by host bone, failure always occurred by demarcation alone or in association with supero-medial migration. Rim defects significant enough to require reconstruction were seen in only 4 of these 45 patients (9%). Failure by supero-lateral migration was only seen in the cases of DDH where the socket was left uncovered or where the socket had fractured.

Conclusions: In this young age group series cemented acetabular components performed well, failed predictably and were relatively straightforward to reconstruct.

The pattern of socket failure can be reliably predicted from the original post-operative x-rays. Care should be taken to ensure adequate supero-lateral coverage in order that demarcation and migration leave an intact rim for reconstruction.

Introduction: Recurrent Instability of the hip remains a difficult problem to treat successfully. The Posterior Lip Augmentation Device (PLAD) is a useful option where there is no gross mal-orientation of the components.

Methods: A retrospective single surgeon review was performed to identify patients who had undergone application of a PLAD to treat recurrent instability. Patients with less than 12 months follow up were excluded.

Results: 14 patients were identified with an average age of 75.5 years (Range 59 – 90 years). There were 7 cases of trochanteric non-union as a result of previous surgery. The mean follow up was 26 months (Range 13 – 41 months). In 13 patients there have been no further instances of dislocation. 1 patient went on to dislocate again and has now undergone a socket revision.

Conclusion: Application of the Posterior Lip Augmentation Device is a well tolerated procedure with very favourable success rates (93%). Given the limited morbidity and short operating time associated with this surgical option it provides a predictable outcome in cases where the original components are well orientated and securely fixed.

Introduction: Revision hip arthroplasty places a significant burden on hospital resources. Huge pressure is being placed on the orthopaedic community to alter practices with respect to implant selection and bearing surfaces in order to try to reduce the likelihood of revision due to aseptic socket loosening. To date there is little clinical evidence to support these changes.

Aim: To review the case mix requiring revision surgery at a specialist arthroplasty unit in order to identify the common reasons for failure of primary arthroplasties.

Methods: A retrospective single surgeon review was performed to identify patients who had undergone revision hip surgery over the study period. The reasons for revision were identified for all cases. Particular attention was paid to the cases with aseptic socket loosening to determine the time to revision for these cases.

Results: 176 revision procedures were performed between October 2001 and May 2005. In 74 (42%) cases aseptic socket loosening was identified (average socket survival 15.4 years). In 16 cases this was the sole cause for revision. In 58 cases the femoral component was also loose. 102 (58%) cases were performed for other reasons. Dislocation was the cause in 14%, femoral component loosening in 20%, infection in 18% and fracture in 6%. Aseptic loosening of cemented sockets less than 10 years old was only seen in 7 (4%) cases.

Conclusions: Aseptic loosening of cemented sockets less than 10 years old was the least common cause of revision in this series. Cemented polyethylene acetabular components continue to provide a satisfactory bearing surface on the acetabular side of total hip arthroplasties. We recommend caution when interpreting the information provided with new products with respect to the benefits of different fixation and bearing surfaces for the majority of patients.

Recently, there has been a reluctance to perform hip arthrodesis. The number of patients requiring the conversion from hip arthrodesis to arthroplasty has also decreased. We present the functional results following conversion of hip arthrodesis to total hip arthroplasty at a specialist hip centre.

76 patients who underwent conversion of hip arthrodesis to total hip arthroplasty between 1963 and 2000 at the Centre for Hip Surgery, Wrightington Hospital, were included in this retrospective study. 9 patients died of unrelated causes and 7 patients were lost to follow up. The functional scoring was performed using the Merle d’Aubigné and Postel score.

The mean age at the time of surgical hip arthrodesis was 16.7 years and at the time of conversion was 48.7 years. Back pain is the most common indication for the conversion. All the patients were pleased with the clinical outcome following conversion to Arthroplasty. 6 patients had postoperative complications. The mean Merle d’Aubigné and Postel score increased from 8.97 to 13.46 at the latest follow-up. The mean wear rate was 0.06 mm/year. Survival of hip arthroplasty was 92.78 % at 18 years.

Conclusion: Our series demonstrates good outcome and patient satisfaction and high survival of the arthroplasty following the conversion from arthrodesis. Hip arthrodesis could be considered as a holding procedure in selected group of young patients with a later successful conversion to arthroplasty.

To determine socket survivorship in DDH based on the severity of hip dysplasia, we carried out a retrospective study of 283 cemented total hip replacements carried out at Wrightington. The hips were classified according to the Crowe and Hartofilakidis classifications. Revision was used as the end point for prosthetic survivorship. The results were analysed statistically using SPSS for Windows

The mean age at time of surgery was 42.6 years with a mean follow-up of 15.7 years. The acetabulum was grafted in 46 cases. The commonest cause for revision was aseptic loosening of the acetabular component (88.3%). 254 procedures were carried out through a transtrochanteric approach with a direct lateral approach used for the remaining mildly dysplastic hips. At 10 years 5.3% of dysplastic, 14.8% of low dislocation and 51.1 % of high dislocation hips were revised.. At 10years 6% of Crowe Type1, 8.5% of Type2, 25.5% of Type3 and 39.2% of Type4 hips were revised. At 20 years 24% of dysplastic, 45% of low dislocation and 88% of high dislocation hips were revised. At 20years 27.3% of Crowe Type1, 29.3% of Type2, 63.3% of Type3 and 84.4% of Type4 hips were revised. The 20 year survival of patients less than 50 years of age at the time of surgery was 61% as compared to 92% survival in patients more than 50 years of age. The mean age of patients in the revised group was 35 years as compared to 45 years in the non-revised group.

Conclusion: This study demonstrates satisfactory results in dysplastic hips following cemented total hip replacements. With increasing severity of hip dysplasia there is a higher rate of premature failure of the acetabular component. There is adverse correlation between age and survival of the acetabular component. There is a dramatic increase in cup failure between 10 and 20 years.

Patients undergoing total hip replacement (THR) often require further orthopaedic surgery including other primary lower limb joint replacements and revision surgery in their lifetime. We analysed the 10-year data of 552 patients who underwent primary total hip replacement between April 1991 and March 1992 at our institute. Data were available for all patients before the index operation. 77% of patients attended their 5-year review and 67% attended their 10-year review. 233 (42%) had had or subsequently had the opposite hip replaced. 30 patients (5%) had a knee replaced and 19 (3%) had both knees replaced. 4.4% underwent revision surgery.

Conclusion: nearly half the total number of these patients will in due course require the opposite hip replaced. 13% will need another major joint surgery (ie revision or TKR). At £6138 for a primary THR and £8500 for revision THR, and the cost of radiographs (£60) and follow-up appointment (£60), the approximate cost implications on a conservative estimate are £13,000.000. These factors including cost implications and human resource requirements will have significant influence on future planning of health care trusts.

Introduction: Trans-trochanteric approach to the hip joint has become less popular in recent years mainly due to problems associated with trochanteric non-union. Although reported incidence of dislocation is low when the trochanter unites following the trans-trochanteric approach, the radiographic appearance of an ununited high flying trochanter with broken wires is distressing for patient and surgeon.

Aim & objective: The aim of our study was to determine if trochanteric non-union was associated with a higher incidence of revision for mechanical failure.

Method: The case notes and radiographs of 371 patients operated between 1979 and 1989 by two senior surgeons were reviewed. The mean follow-up was 16.7 years (Range 15–25 years).

Results: 19.6% (66/336) patients with the trochanter united and 20% (7/35) with trochanteric non-union had been revised at the latest follow up. The difference was not found to be statistically significant (p value > 0.1, Odds Ratio 1.02).

Conclusion: This study showed that trochanteric non-union following primary total hip replacement did not increase the incidence of revision surgery over a period of 25 years.

Background: With the foreseeable increase in demand for revision hip surgery, it is likely that orthopaedic surgeons working in district general orthopaedic units will undertake an increasing number of secondary procedures. This article set out to determine whether a single orthopaedic surgeon, working in a district general hospital, could achieve results comparable to those obtained by surgeons working in specialised tertiary referral centres.

Patients and methods: Complete records and serial radiographs of 72 patients (76 hips) having revision total hip arthroplasty by a single surgeon and follow-up of at least 1 year, were reviewed by an independent observer.

Results: The mean follow-up period was 4 years. Indications for revision were aseptic loosening (N=51), sepsis (N=16), fracture (N=3), dislocation (N=2), and other (N=4). Complete cement removal was achieved in 97% of acetabular components revised and 88% of femoral components revised. There were no documented complications in 68% of revised hip prostheses. The complications of the remaining cases comprised trochanteric bursitis (9%), dislocation (10%), thromboembolism (5%), periprosthetic fracture (1%) and infection of the revised prosthesis (1%). None of the cases studied died as a direct result of surgery. All radiographic parameters measured were improved by revision of the prostheses.

Conclusions: Orthopaedic surgeons working in district general hospitals performing 5 to 10 revision hip arthroplasties per year can achieve results comparable to those of surgeons working in specialised units.

Aseptic loosening is the commonest cause for revision of total hip replacements. Advances in technique have improved femoral fixation, but acetabular survival is unchanged. Little has been published about the pressures achieved during acetabular insertion.

Using an experimental model, an acetabular cup was inserted into a model acetabulum using standard surgical technique. The pressures achieved under the centre of the cup, and also just beneath the superior flange were recorded over time via a data logger. The experiment was repeated for different insertion times, cup sizes and cement volumes. To reduce experimental error four runs for each constraint were performed. Complex pressure/time curves were produced for each run of the experiment. An average was then plotted. Peak and mean pressures were calculated from these curves.

Central pressures were found to be similar to flange pressures, although pressure under the flange decayed more quickly as the cement cured.

As long as the cup was inserted during the working phase cement then peak and mean pressures were similar.

Use of a double cement mix with a 43mm cup showed a large increase in pressures over the single mix (peak 693 to 957mmHg, mean 297 to 485mmHg). Both were statistically significant (ANOVA: peak p=0.018, mean p=0.008). Peak pressure occurred with cup insertion, rather than with pre-pressurisation.

The 47mm cup showed an increase of peak and mean pressures over the 43mm cup with a single mix (peak=800mmHg, mean=384mmHg). The pressures for the 47mm cup with a double mix were less than those of the 43mm cup with a double mix.

Insertion of the cup without pre-pressurisation resulted in a rapid loss of pressure, and low mean pressures were achieved (double =262mmHg, single=80mmHg).

Our experiment shows the need for pre-pressurisation, and that the timing of cup insertion is not critical as long as it is during the working phase of the cement. We have also shown an increase in pressure with a larger cup with a single mix of cement even though volumes were adequate to fill the space between cup and acetabulum. Interestingly we obtained significantly increased pressures with a smaller cup and a double volume of cement, this area needs further study.

Introduction: Arthodesis provides a durable, painless and stable hip. Conversion to arthroplasty was has been recommended to relieve the excessive stresses in the neighbouring joints. We present the long term results following conversion of hip athrodesis to total hip artho-plasty at specialist hip centre. Method and material: 67 patients underwent the conversion between 1963 and 2000 at the centre for hip surgery, wrightington hospital were included in the study. 45 patients are available for the evaluation. Merle d’ Aubigne and Postel as modified by Charnley was used for clinical scoring. The most recent radiograph in patients with surviving arthoplasty was analysed. Results: The mean age at the time of arthodesis was 16.8 years. The conversion to hip arthroplasty was performed after a mean period of 32.3 years (range 12 to 54 years). The mean folowup was 16.37years (range 2–28). The mean Merle d’ Aubigne and Postel score increased from 7.95 to 13.45 postoperatively. All the patients were delighted with the conversion. 7 patients had revision and 1 had pseudoarthrosis. Conclusion: Hip arthrodesis is a useful holding procedure for young persons with painful hip. This could be successfully converted to Hip arthroplasty after an interval of relatively high physical activity during young adult life.

Patients undergoing total hip replacement (THR) often require further orthopaedic surgery including other primary lower limb joint replacements and revision surgery in their lifetime. We analysed the 10-year data of 552 patients who underwent primary total hip replacement between April 1991 and March 1992 at our institute. Data was available for all patients before the index operation. 77% of patients attended their 5-year review and 67% attended their 10-year review. 233 (42%) had had or subsequently had the opposite hip replaced. 30 patients (5%) had a knee replaced and 19 (3%) had both knees replaced. 4.4% underwent revision surgery.

Concluding, nearly half the total number of these patients will in due course require the opposite hip replaced. 13% will need another major joint surgery (ie revision or TKR). At £6138 for a primary THR and £8500 for revision THR, and the cost of radiographs (£60) and follow-up appointment (£60), the approximate cost implications on a conservative estimate are 13 million pounds. For a single surgeon undertaking 40 THRs in a single year the cost would be approximately £900,000. In addition, the surgeon in 10 years practice would create enough work to last him the rest of his working lifetime. These factors including cost implications and human resource requirements will have significant influence on future planning of health care trusts.