Little is published about the use of cementless conical stems in primary hip arthroplasty for congenital hip disease. A conical stem was designed in the 80’s by Prof. Wagner. The stem is made of a rough blasted titanium alloy with a cone angle of 5° and 8 sharp longitudinal “ribs” that cut into the inner cortex, designed to achieve rotational stability: The ribs depth of penetration ranges between 0.1 and 0.5 mm and is also very important to achieve osteo-integration. The CCD angle is 135°. The stem is straight and can be implanted in any degree of version thus being very useful for dysplastic arthritis with significant femoral neck anteversion.

Between 1993 and 1998 the senior author (RB) implanted 92 conical stems in 88 consecutive patients with dysplastic arthritis. The acetabular component was cementless and titanium with tridimensional porosity. The articulating surface was a second generation Metal-on-Metal.with a femoral head of 28 mm. According to the Hartofilakidis classification 63 patients had type A, 18 type B and 11 type C.

The average follow-up was 11.2 years (range 10.1–14.8)

Using the Harris Hip Scoring system we had 82 (89%) satisfactory results, with excellent correction of pre-op pain (42/44 Harris) and no case of anterior thigh pain; 88% of patients had no or slight limp at follow-up. No patient required revision of the stem, but one cup required revision for loosening (Type C class). We had one dislocation (1%) that was treated conservatively

Radiographically, all stems were osteo-integrated, 17% showed some resorption in femoral zone 1 and 7. In the same zones we observed 4 cases of real osteolysis without loosening. No radiolucent line was observed in other femoral zones. In the acetabular side we had 13 cases (14%) of radiolucency, but in only 1 case (1%) was it progressive.

A straight conical titanium femoral stem gave very satisfactory clinico-radiographical results in dysplastic arthritis at a mean of 11.2 years of follow-up.

i Background and purpose Although there are now many trials of the effectiveness of back pain treatments, there are few robust cost effectiveness analyses of these treatments.

ii Methods and Results: We analysed the cost-effectiveness of adding to ‘best care’ in general practice for patients consulting with low back pain: spinal manipulation; exercise classes; or manipulation followed by exercise (‘combined treatment’) alongside the UK BEAM trial. We collected health care resource use and health-related quality of life data at baseline, 3 and 12 months from 1334 trial participants. We estimated participant-specific quality-adjusted life-years (QALYs) and costs over the 12 months study period. Over one year mean treatment costs relative to ‘best care’ were: £195 (95% credibility interval £85 to £308) for manipulation; £140 (£3 to £278) for exercise; and £125 (£21 to £228) for combined treatment. All three active treatments increased participants’ average QALYs compared with ‘best care’ alone. For each extra QALY that combined treatment yielded relative to ‘best care’, it cost £3,800; in economic terms it had an ‘incremental cost-effectiveness ratio’ (ICER) of £3,800. Manipulation alone had an ICER of £8,700 relative to combined treatment. If the NHS were prepared to pay at least £10,000 for each extra QALY (lower than previous recommendations in the UK), manipulation alone would probably be the best strategy. If manipulation were not available, exercise would have an ICER of £8,300 relative to ‘best care’.

iii Conclusions The UK BEAM spinal manipulation package is a cost-effective addition to ‘best care’ for back pain in general practice.