Introduction: The DePuy ASRTM hip resurfacing system has been in clinical use since 2003. Its design features include a diametral clearance of 100–150 microns for optimal wear, and thinner components for improved bone preservation. Three of the six designer surgeons have pooled their clinical experience from three countries.

Methods: 1030 consecutive cases have been studied prospectively at annual intervals,. There were 379 females (average age 56.8 years, 16–71 years) and 579 males (average age 56.9 years, 21–75 years). 86% of patients had a primary diagnosis of Osteoarthritis. Follow up data has been collected by patient questionnaire, radiographs and clinical review. All retrieved specimens have been analysed

Results: The size of implants used varied from 46mm outside diameter acetabular component to 70mm

The Harris Hip Score improved from a pre-operative mean of 56.99 to 97.12 at the latest follow up, and 60% of patients were scored at 100. At the latest follow up, 91% of patients scored 6 or above on the UCLA activity score; indicating at least regular participation in moderate exercise.

There were no dislocations and no clinically evident DVT’s or PE’s

There have been 11 revisions for fracture (1.06%). Five of these were intra-operative fractures, and six of these took place in patients aged over 50years. Fractures occurred in 3.1% of patients 65 years or more and in 0.5% of patients under 65 years(P< 0.05). In addition there were three revisions for cup loosening (0.29%) all in women over 60 years, three for unexplained pain (0.29%), one for impingement and subluxation, and one for infection(0.1%) Five patients have died with the resurfacing in situ (0.51%), for unrelated causes.

The 3-year cumulative survival rate for all patients and all components was 97.4%. For 425 patients under 55 years the cumulative survival rate was 99.4%, aged under 65 years was 98.3%, and aged over 65 yrs was 94.8 %.

Discussion: Clinical results of this all-inclusive cohort of patients using a new resurfacing implant have been typical of other resurfacing systems and confirm excellent relief of pain and rapid return to an active lifestyle. The failures were evident within the first year after implantation, with no revisions occurring after 2 years. Cup loosening has been a rare complication associated with older females and only 0.29% of patients have undergone revision surgery for pain which could not be attributed to implant loosening or infection.

Introduction: Over 20,000 DePuy ASRTM hip resurfacing procedures have been performed since 2003, the implant design applying modern engineering and tribological principles to minimise metal-on-metal bearing wear. Enhanced fixation of both components, high-carbon cobalt-chromium alloy, reduced material thickness and small diametral clearance 100–150 microns are all supported by non-clinical testing. There are published reports of very low wear on hip joint simulators (Dowson D, et al. 2004 Dec;19(8 Suppl 3):124–30.), low wear on retrieval analysis (Morlock MM et al 1: Proc Inst Mech Eng [H]. 2006 Feb;220(2):333–44.) and excellent clinical results (Siebel T et al, Proc Inst Mech Eng [H]. 2006 Feb;220(2):345–53. We recently reported median whole blood chromium and cobalt ion levels of 1.56 ppb and 1.65 ppb at 24 months (Cobb AG et al, British Orthopaedic Association Congress 2007)

Methods: 1030 consecutive cases carried out by 3 of the surgeon-designers between July 2003 and May 2007 have been studied prospectively at annual intervals. 2 to 4 years follow-up data is available on 293 hips.

Results: There have been 11 revisions for fracture (1.06%), 6 in patients aged over 65 years(3.4%), 5 in patients aged up to 65 years (0.6%) (P< 0.001).

There have been 3 revisions for cup loosening (0.29%) and 3 for pain (0.29%). 5 patients have died (0.51%). There was one revision for infection and one for impingement.

Average Harris Hip Score rose from 57.0 to 97.1, and 60% of patients scored 100.

UCLA activity score was 6 or over in 91%, and the median score was 7.5.

All failures were evident by 12 months

The Cumulative Survival Rate at 3 years was 97.4%,, 99.5% for 55 years and under, 98.3% for under 65 years, and 94.2 % 65 years and over.

Discussion: The 2 to 4 year clinical follow-up of the latest generation of surface hip implants is satisfactory. Technical errors during implantation or patient selection accounted for most of the failures. The risk of failure between 12 months and 4 years is low.

Patients with DDH are known to be at risk of early degenerative changes to their hips. To date, no consensus exists as to the most appropriate management of this group, with many surgical options being associated with specific complications such as dislocation and early wear. In addition, modern resurfacing methods are considered by many to be contra-indicated in patients with DDH due to the technical difficulty of the procedure.

This prospective study analyses a single surgeon series of known DDH hips that underwent metal on metal resurfacing from November 1999 to July 2004 inclusive.

There were 31 resurfacings carried out on 28 patients (11 males, 17 females). The mean age of the study group at the time of surgery was 43.9+/−9.1 years. No patient was lost to follow up. Pre-operatively, 23 hips were classified as Crowe I (n=9), II (n=5), III (n=5) and IV (n=4). Patients were followed up to a mean of 46.4+/−18.1 months. The mean Harris Hip scores were 54.9+/−9.3 pre-operatively and 98.1+/−4.9 post-operatively (p< 0.001, Student’s t-test). Using the UCLA activity profile, the mean scores were 3.2+/−1.0 pre-operatively and 6.4+/−1.8 post-operatively (p< 0.001, Student’s t-test).

Although the management of young patients with early degenerative changes secondary to DDH remains controversial, the results of this study suggest that not only is resurfacing technically possible even in advanced cases, it also offers excellent functional outcomes and should be considered in appropriate cases.

Introduction: We performed a clinical and radiological study to determine the functional outcome in terms of union and shoulder function and other related complications associated with treatment of humeral diaphyseal fractures with Intramedullary nailing.

Methods and Patients: A review of 100 consecutive humeral nailing over a period of four years performed solely for diaphyseal fractures using Russell Taylor nails.

51 male and 49 female.

Out of 100 nails, 90 were statically locked while 9 were locked proximally and 1 was locked only distally.

The outcomes were assessed clinically, radiologically and using the Disability of Arm Shoulder and Hand (DASH) function scoring system.

Statistically Cronbach’s alphas were calculated for the three scales of the DASH instrument. These scales were the function/symptom scale consisting of 30 items, sports/music module containing 4 items, and work module comprising 4 items.

Medians (interquartile ranges) and ranges are presented for numerical variables.

Mann-Whitney U tests (two-tailed) and Univariate and multivariate regression analysis were used.

Results: 90% fractures united initially and 4% had delayed union, giving cumulative union rate of 94%. Six non unions required a second procedure.

The DASH function scale scores was categorised into good 71 patients 85.5% (Score 0-< 25),

Medium 4 patients 4.8% (Score 25-< 40) and Poor 8 patients 9.6% (Score 40+).

Univariate and multivariate regression analysis showed, Increasing age (adjusted OR=0.96,95%CI 0.93–0.99,P< 0.01) and communited compared to simple fractures (adjusted OR=0.12,95%CI 0.03–0.45,P< 0.01) were associated with reduced likelihood of attaining full range of motion.

Male patients (unadjusted OR=2.37,95%CI 0.90–6.25,P=0.08) and patients involved in RTA compared to falls (unadjusted OR=4.5,95%CI 0.96–21.07,P=0.06) were associated with higher likelihood of attaining full range of motion.

85 % had no complication, while 15 % had complications.

One nerve palsy and one case of infection.

Seven patients required nail removal and 3 required removal of proximal locking screw.

Conclusion: To date, we have the largest series in the literature of antegrade nailing for diaphyseal fractures. In our series the vast majority of patients achieved desired functional outcome and union, hence we recommend the use of intramedullary nailing for humeral diaphyseal fractures. By eliminating surgical technique errors, complications can be reduced further and even higher union rates can be achieved.

Heterotopic ossification (HO) is a common complication following total hip replacement with a number of papers reporting an incidence of greater than 40%. In an effort to reduce the degree of contamination of the abductor muscle bed with osteoprogenitor cells, we used a plastic protective shield during the preparation and reaming of the femoral head in the hope that this would result in a decreased incidence of HO.

One hundred and forty consecutive metal-on-metal resurfacing procedures (mean age 52.3 years) utilizing the Birmingham hip prosthesis were performed between March 1999 and May 2002. Pre-operative diagnosis included osteoarthritis (105), Dysplasia (19), AVN (8), Inflammatory arthropathy (8). In the first 70 cases wet swabs packed around the femoral head were used in an attempt to reduce bone contamination. For all subsequent cases, bone contamination was controlled by the use of the plastic shield. Patients were reviewed clinically and radiologically at a mean of 36.1 (range 24–62) months post operatively. Pre-operative and follow up radiographs were assessed for presence of HO according to the Brooker classification. Harris hip and UCLA activity scores were recorded pre- and post-operatively on all patients. Three patients were lost to follow up.

Eighteen patients (12.9%) were noted to have HO on follow up radiographs. Sixteen patients in the initial group when no shield was used developed HO (Brooker I [10], II [2] & III [1]). Only two patients developed HO (Brooker I) following introduction of the protective shield. This modification in surgical technique was statistically significant in decreasing incidence of HO. All patients with radiological abnormalities were asymptomatic. We propose that this protective shield should be used during resurfacing hip arthroplasty as prophylaxis against ectopic new bone formation.

We undertook this study to determine whether the concerns regarding early complications following hip resurfacing were justified. One hundred and twenty-nine consecutive resurfacing procedures (118 patients, mean age 52.3 years) utilising the Birmingham hip prosthesis were reviewed at a mean of 36.1 (range 24–62) months. Pre-operative diagnosis included osteoarthritis (94), Dysplasia (19), AVN (8), Inflammatory arthropathy (8). Immediate post-operative x-rays were analysed for prosthesis placement and interface gaps. Follow up films were assessed for lucent lines, osteolysis, bone resorption and component migration. Harris hip and UCLA activity scores were recorded pre and post operatively on all patients. Three patients were lost to follow up. Five cases were revised. Three cases due to femoral neck fracture. One patient developed late infection and subsequently fractured. All four patients underwent successful revision to an uncemented stem. One patient required revision of the acetabular component due to migration following a fall three years postop. Five cases of osteolysis were seen (Acetabulum (3), Femur (2)). Four cases of bone resorption at the femoral neck were noted. Two patients developed significant heterotopic ossification (Brooker II & III). All patients with radiological abnormalities were asymptomatic. The mean Harris hip score pre-operatively was 56.4 increasing to 97.5 post-operatively. The mean UCLA activity score pre-operatively was 3.3 increasing to 7.4 post-operatively. Kaplan-Meier survivorship was 94.7% at 5 years. Surface replacement gives excellent clinical results and offers significant advantages over conventional hip replacement. Long-term results are awaited to fully evaluate the effects of resurfacing arthroplasty.

Introduction: The need to meet the demands for a hip replacement that will allow young patients to maintain a high activity level with the expectation of enhanced longevity has been the Holy Grail of modern orthopaedic practice for some time. Novel bearing surfaces and methods of component fixation have not as yet managed to sate this need. The Birmingham Hip Resurfacing (BHR) offers a number of theoretical advantages for this demanding patient group. The metal on metal bearing couple facilitates fluid film lubrication and thus minimises wear and reduces osteolysis. The large head size enhances stability minimising the risk of dislocation during strenuous activity. Resurfacing anatomically restores hip geometry facilitating normal hip biomechanics. Finally, in the event of failure preservation of bone stock makes revision surgery less challenging.

In the absence of long-term outcome studies for the BHR these advantages remain theoretical. Furthermore, reports of good short and medium term results require corroboration at independent centres. This paper presents early results in a large series of patients in such an independent unit.

Patients and Methods: Between March 1999 and December 2001, 102 patients were deemed suitable for hip resurfacing. Patients were felt to be suitable if they were active, had no comorbid conditions that might compromise bone quality and were sixty five years old, although this was not an absolute figure. Pre-operative work up was performed to exclude generalised disease that might compromise bone quality, including bone density measurement where appropriate. Baseline Harris hip scores were performed preoperatively and at latest follow up. Operative details were recorded along with per-operative and other complications. Patients were followed up clinically and radiologically at an average of 13 months (range 3–30 months).

Results: There were 86 male and 16 female patients with an average age of 47 (range 28–66) for the men and 48 (range 21–55) for the women. Five patients had acetabular dysplasia as a primary diagnosis, four had AVN, one had post-traumatic arthritis and the remainder had primary osteoarthritis. There were no patients with inflammatory arthritis or severe dysplasia.

Average Harris hip score pre-operatively was 52 (range 25–65). This had improved to 89 at latest follow-up. All operations were performed via an extended posterior approach. No patients had neuro-vascular complications. Average hospital stay was 6.5 days; average transfusion requirement was 0.3 units.

There were two spontaneous femoral neck fractures, both presenting with pain at approximately 2 months. Both were revised to conventionally stemmed femoral components with large metal heads (Corin^TM). One patient presented with pain at 8 months and X-rays showed a fractured neck of femur. At revision, pus was found and diagnosis of infection was assumed. It was treated with a one-stage revision.

93 patients said they were very satisfied with their outcome and two were moderately satisfied. All patients who were more than six months post op (67 patients) had returned to their previous work (41 office work, 16 retailing, 10 farming). Twenty-six patients had returned to active leisure pursuits including running, golf, horse-riding and tennis.

Discussion: When considering new advances in arthroplasty, long-term outcome studies are necessary before any firm conclusion can be drawn regarding ultimate efficacy. This study, however, confirms that BHR is safe and gives good short-term results. While there is no substitute for long-term studies, we feel that these early results are encouraging and justify continued work with the procedure in the context of a critical prospective study.

Introduction: Graft selection for anterior cruciate ligament (ACL) reconstruction remains controversial. The use of hamstring graft is associated with less harvest site morbidity but concern has been expressed with tibial fixation for these grafts. We recently began to use the new Intrafix^TM ACL tibial fastener with hamstring grafts. It claims greater pullout strength and greater graft contact with circumferential healing of the tendons to the bone tunnels. Our objective was to assess the short term functional results with the new fixation as well as donor site morbidity.

Methods: We reviewed 64 patients who had a primary ACL reconstruction (quadrupled semitendinosus and gracilis tendons with Endobutton^TM femoral fixation) performed at least six months previously. They were assessed using self-administered International Knee Documentation Committee (IKDC) knee evaluation forms and the Lysholm knee score.

Results: The average patient age was 25 years (range 16–49 years) with average follow-up of 10.5 months (range 7–15 months). There were 57 males and 7 females. Forty two patients returned the questionnaires and 26 patients returned for examination. Over half of the patients (38/64) had meniscal tears. The mean IKDC score was 82.6 (SD 13.0) and the mean Lysholm score was 85.0 (SD 12.6). Sixty nine percent of patients (29/42) had knees rated excellent or good using the Lysholm knee score. Eighty eight percent (23/26) of the patients examined had normal or nearly normal knee function as graded by the IKDC. No patient had anterior knee numbness. Four patients had arthroscopic debridement and washout for knee pain and two patients had a wound haematoma at the donor site.

Conclusions: The Intrafix^TM ACL tibial fastener provides sufficient early fixation to allow patients undergo a standard accelerated rehabilitation regime, leading to good functional recovery at 6 months. Our choice of ACL graft also results in low donor morbidity.