Background: The principal cause of late failure of the cemented acetabular component is aseptic loosening. The acetabulum is a horse shoe of cortico-cancellous bone surrounding a cortical fovea. The cancellous bone becomes denser and less porous peripherally, limiting cement penetration. A radiolucent line in the DeLee and Charnley zone 1 of the acetabulum increases the risk of loosening of the acetabular component by 38.8 times. We propose that the use of 0.5cm keyholes in zone 1 decreases the incidence of zone 1 radiolucency.

Materials and Methods: Two contemporous cohorts of 100 patients were analysed for the incidence of zone 1 radiolucency on the first post operative film. In one cohort, zone 1 keyholes were used and in the other they were not. The films were analysed independently by two blinded investigators. The incidence, length and thickness of any radiolucency were recorded.

Results: The cohort of patients in which zone 1 keyholes were used demonstrated a 9% incidence of any zone 1 radiolucency, 8% were of 1mm width or greater and 2% involved 50% or more of the zone. In the cohort of patients in which zone 1 keyholes were not used the incidence of zone 1 radiolucency was 40% with 29% demonstrating a width of 1mm or greater and 12% affecting 50% or more of the zone.

Conclusions: The use of peripheral keyholes aids penetration of cement into the denser peripheral acetabular bone as demonstrated by decreased rates of post operative zone 1 radiolucency. This decrease in the incidence of early radiolucency should result in lower rates of subsequent loosening of the acetabular component.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

Introduction: Total hip replacement (THR) and total knee replacement (TKR) are widely accepted as effective surgical procedures to alleviate chronic joint pain and improve functional ability. Clinical evidence suggests that joint replacement results in excellent outcomes. Traditionally, reporting of outcomes has been focused on implant survivorship and surgeon based assessment of objective outcomes, such as range of motion, knee stability and radiographic results. However, because there is a discrepancy between patient and clinician ratings of health, patient-reported outcome measures have been validated to allow patients to rate their own health, thereby placing them at the centre of outcome assessment. The aim of this study was to compare the mid-term functional outcomes of TKR and THR using validated patient-reported outcome measures.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR or TKR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Participants completed an Oxford hip score (OHS) or Oxford knee score (OKS). The Oxford questionnaires are self-report joint-specific measures that assess functional ability and pain from the patient’s perspective. They consist of 12 questions about pain and physical limitations experienced over the past four weeks because of the hip or knee.

Results: 1112 THR patients and 613 TKR patients returned a completed questionnaire, giving a response rate of 72%. The median OKS of 26 was significantly worse than the median OHS of 19 (p< 0.001). TKR patients experienced a poorer functional outcome than THR patients on all domains assessed by the Oxford questionnaire, independent of age. The percentage of patients reporting moderate-severe pain was two-fold greater for TKR than THR patients (26% vs 13%, respectively).

Conclusion: This survey found that TKR patients report more pain and functional limitations than THR patients at 5–8 years post-operatively, independent of age. The finding that over a quarter of TKR patients reported moderate-severe pain at 5–8 years post-operative indicates that a large proportion of people are undergoing major knee surgery that is failing to achieve its primary aim of pain relief. This raises questions about whether patient selection for TKR is appropriate. To improve patient selection, it may be necessary to have a preoperative screening protocol to identify patient factors predictive of a poor outcome after TKR. Currently, no such protocol exists and this is an area of orthopaedics requiring further research.

Introduction: Although THR can provide excellent pain relief and restore functional ability for most patients, there is a proportion of patients who experience a poor functional outcome after THR. One factor that could contribute to a poor outcome after THR is leg length discrepancy (LLD). Restoration of leg length is important in optimising hip biomechanics and LLD has several consequences for the patient, including back pain and a limp. Assessment of LLD using radiographs is time consuming and labour intensive, and therefore limits large scale studies of LLD. However, patients self-report of perceived LLD may be a useful tool to study LLD on a large scale. Therefore, the aim of this postal audit survey was to determine the prevalence of patient-perceived LLD after primary THR and its impact on mid-term functional outcomes.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Several questions about LLD were included on the questionnaire. Firstly, patients were asked if they thought that their legs were the same length. For those who thought their legs were different lengths, they were asked if the difference bothered them, whether the difference in length leg was enough to comment upon, and whether they used a shoe raise. Participants also completed an Oxford hip score (OHS), which is a self-report measure that assesses functional ability and pain after THR, including limping

Results: 1,114 THR patients returned a completed questionnaire, giving a response rate of 73%. 329 patients (30%) reported that they thought their legs were different lengths. The median OHS for patients with a perceived LLD was 22, which was significantly worse than the OHS of 18 for patients who thought their legs were the same length (p< 0.001). Of the 329 patients with a perceived LLD, 161 patients (51%) were bothered by the difference, 65 patients (20%) thought the discrepancy was sufficient to comment upon and 101 patients (31%) used a shoe raise. 31% of patients with LLD limped most or all of the time compared to only 9% of patients without LLD.

Conclusion: In conclusion, this study found that the prevalence of perceived LLD at 5–8 years after THR was 30%. Of the patients with LLD, over 50% were bothered by the LLD and over a third used a shoe raise to equalise leg lengths. Patients with perceived LLD have a significantly poorer self-report functional outcome than those patients without LLD. It is therefore important that patients are informed pre-operatively of the high risk of LLD after THR and the associated negative impact this may have on their outcome.

Introduction: Avascular necrosis of the femoral head may play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and March 2006 by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. There were an equal number of procedures for each approach. 1.5 gms of intravenous cefuroxime was administered following caspsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime. The average time taken to prepare the femur and take samples was 8.5 minutes.

Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 – 19.1) compared to the posterior approach (mean 5.6mg/kg; CI 3.5 – 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable.

Discussion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure.

Introduction: The long-term results of 70 Harris-Galante I uncemented acetabular components implanted in 53 patients who were under 50 years of age at the time of their hip arthroplasty are presented.

Methods: Follow up was both clinical, using Oxford and Harris Hip scores, and radiological. Kaplan-Meier survivorship analysis was performed to calculate the survivorship of the acetabular components. Failure was defined as either liner exchange or acetabular component revision due to aseptic loosening, osteolysis, infection or dislocation.

Results: The mean age of the patients at the time of surgery was 40 years (range 19–49 years), with follow up of between 12 and 16 (mean 13.6) years. All patients’ acetabular components were implanted primarily with cemented femoral components. The mean Oxford Hip Score at the end of the follow-up period was 20 out of 60 (range 12–46) and Harris Hip Score 81 (range 37–100).

At the end of the follow up period, 11 of the 70 acetabular components (polyethylene liner or the acetabular shell) had been revised. The cumulative survival was 94.0% (95% confidence interval 88.4–99.7) with revision of the metal shell as the end point, and 84.0% (95% confidence interval 74.5–93.5) with revision surgery of the acetabular shell or liner due to any reason as an end point. Radiologically, 4 patients require acetabular revision and 22 patients had femoral osteolysis in gruen zone 7, indicative of polyethylene failure. This gave a combined revision, impending revision and zone 7 osteolysis cumulative survival of 55.3% (95% confidence interval 40.6–70.0).

Discussion: In contrast to cemented acetabular components which undergo aseptic loosening and give groin pain, high density polyethylene lined metal shells do not give groin pain but cause silent acetabular and femoral osteolysis. The danger time for osteolysis is between 10–20 years, therefore follow up at that time is essential.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

Introduction: Dividing the short external rotators 2 cm from their insertion into the femur should preserve the deep branch of the medial femoral circumflex artery. Our aim was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty comparing two posterior approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 20 patients by two different surgeons between September 2005 and November 2006. Patients were divided into two equal groups according to approach. One surgeon used the extended posterior approach and the other a modified posterior approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime.

Results: There was no statistical difference between the concentration of cefuroxime in bone when using the modified posterior approach (mean 5.6mg/kg; CI 3.6 – 7.8) compared to the extended posterior approach (mean 5.6; CI 3.5 – 7.8; p=0.95). In one patient, who had the operation through the posterior approach, cefuroxime was undetectable.

Discussion: The similarity in femoral head perfusion between approaches suggests the blood supply is further impaired by capsulectomy rather than by damaging the MFCA alone.

Introduction: Radial shortening has been associated with a poor functional outcome following a fractured distal radius. Traditionally, outcome has been measured using doctor-based scores such as the Gartland and Werley Scoring System or modifications thereof.

Aims: The aim of this study is to compare patient based outcome scores with the Frykman class of the fracture and radial shortening both at injury and fracture union.

Methods: We followed up 60 patients over 55 who underwent closed reduction and k-wire fixation of distal radial fractures. Outcome was recorded by the Patient Rated Wrist Evaluation (PRWE) score, a validated subjective outcome measure.

Results: No association was found between radial shortening either at injury or fracture union with subjective outcome score but there was a significant association between Frykman Classification and outcome (p< 0.05).

Discussion: Our results showed that for distal radius fractures that united with a moderate degree of radial shortening, increasing Frykman Class was associated with a worse functional score.

Introduction: Displaced Colles’ fractures are usually managed by closed reduction and cast immobilisation. They are reduced initially but frequently lose position because cast immobilisation is an inefficient means of stabilisation. This results in malunion. If position is lost after reduction and cast immobilisation or the fracture is unstable, closed reduction and cast immobilisation is often supplemented by longitudinal k-wire fixation. There is a paucity of literature examining the incidence of unacceptable malunion after closed reduction and k-wire stabilisation.

Aim: The aim of this study was to determine whether closed reduction, longitudinal k-wire fixation and cast immobilisation of displaced fractures of the distal radius avoids unacceptable malunion. A secondary aim was to define the type of fracture best treated by this method.

Methods: 53 patients underwent closed reduction and longitudinal k-wiring of displaced Colles’ fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation.

Results: Manipulation significantly improved fracture position (p< 0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. 73% of fractures manipulated for radial shortening > 2mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. The mean shortening between reduction and fracture union was 1.6mm. This did not correlate with Frykman Class or radial shortening at injury.

Discussion: Closed Reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures not reduced to allow for this later loss of radial length are more likely to malunite. This may compromise functional outcome.

We examined the effect of age, gender, body mass index (BMI), medical co-morbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA).

Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods.

To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univariate and by Logistic regression for multivariate analysis

The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4.

On univariate analysis age above 80 years, age between 70 and 79 years, Body Mass Index > 35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays.

On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks.

This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission.

Aim: To determine the time at which callus is visible on plain radiographs of tibial fractures and hence the appropriate time to order x-rays to assess union.

Method: The radiographs of patients with tibial diaphyseal fractures were graded for amount of callus on a scale of 1 (no callus) to 5 (no visible fracture line) and the time from injury recorded.

Results: 68 patients were identified, with 45 managed non-operatively by cast, 16 with intramedullary nails and 7 with other methods of fixation. Mean time to grade 3 callus (at least 2 cortices) in adults with non-operatively treated fractures was 8.4 weeks and 4.6 weeks for children. Mean time to union (four cortex bridging callus) was 17.6 weeks for adults and 8.1 weeks for children. In the nailed fractures, mean time to radiographic union was 20 weeks.

Conclusions: To assess union in adult tibial diaphyseal fractures, we recommend an x-ray at eight weeks and 16 weeks after injury, providing there are no clinical concerns. For children, the times should be reduced to 4 and 8 weeks after injury, respectively. Nailed tibial shaft fractures should have radiographs at 12 weeks and 18 weeks to assess union.

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.

We investigated the effect of neck dimension upon cervical range of movement. Data relating to 100 subjects healthy subjects aged between 20 and 40yrs was recorded with respect to age, gender and ranges of movement in three planes. Additionally two commonly used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool the CROM goniometer (Performance Attainment Associates, Roseville, MN).

Using multiple linear regression analysis it was determined that sagittal flexion (P= 0.0021) and lateral rotation (P< 0.0001) were most closely related to neck circumference alone whereas lateral flexion (P< 0.0001) was most closely related to a ratio of circumference and length. The uniplanar goniometer has some usefulness when assessing neck motion, comparing favourably to chin-sternal distance that has almost no role.

Neck dimension should be incorporated into cervical functional assessment. One should be wary about recorded values for neck motion from non-validated measurement tools.

We examined the effect of age, gender, body mass index (BMI), medical comorbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA).

Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods.

To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univarate and by Logistic regression for multivariate analysis.

The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4.

On univarate analysis age above 80 years, age between 70 and 79 years, Body Mass Index > 35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays.

On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks.

This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission.

The success of total hip replacement in the young has consistently been worse both radiologically and clinically when compared to the standard hip replacement population.

Methods: We describe the clinical and radiological outcome of 58 consecutive polished tapered stems (PTS) in 47 patients with a minimum of 10 years follow up (mean 12 years 6 months) and compared this to our cohort of standard patients. There were 22 CPT stems and 36 Exeter stems.

Results: Three patients with 4 hips died before 10 years and one hip was removed as part of a hindquarter amputation due to vascular disease. None of these stems had been revised or shown any signs of failure at their last follow-up. No stems were lost to follow up and the fate of all stems is known. Survivorship with revision of the femoral component for aseptic loosening as the endpoint was zero and 4% (2 stems) for potential revision. The Harris hip scores were good or excellent in 81% of the patients (mean score 86).

All the stems subsided within the cement to a mean total of 1.8mm (0.2–8) at final review. There was excellent preservation of proximal bone and an extremely low incidence of loosening at the cement bone interface. Cup failure and cup wear with an associated periarticular osteolysis was a serious problem. 19% of the cups (10) were revised and 25% of the hips (13) had significant periarticular osteolysis associated with excessive polyethylene wear.

Discussion: The outcome of polished tapered stems in this age group is as good as in the standard age group and superior to other non PTS designs in young patients. This is despite higher weight and frequent previous surgery. Cup wear and cup failure were significantly worse in this group, with a higher incidence of periarticular osteolysis.

Introduction: The purpose of this study was to evaluate the effect of preoperative oral ferrous sulphate supplementation on the haemoglobin status of a group of patients undergoing primary THA and the incidence of homologous blood transfusion in them.

Methods: The authors prospectively studied 107 consecutive patients scheduled to undergo primary THA. All the patients were given ferrous sulphate, 200mg twice a day for a minimum of 21 days, six weeks prior to their proposed operation. We excluded patients on medications that can interfere with iron metabolism.89 patients managed to complete the course. To aid compliance the investigators collected tablet bottles after completion of the course. Haemoglobin (Hb), Mean Corpuscular Haemoglobin and Mean Cell Volume was conducted at the start, on the day before surgery and the second postoperative day. The details for blood transfusion were also recorded. We compared these patients to control group of demographically similar 90 patients, who did not have iron supplementation.

Results: 19 patients (21%) were anaemic at the start of the therapy.72 patients had rise in their haemoglobin by a mean of 0.61 g. In the study group16 patients (18%) had a blood transfusion as compared to 23 patients (26%) in the control group. Patients with preoperative Hb above 13.5g did not require transfusion in both study and control group.15 patients in the study group increased their Hb above 13.5 gdl, and were likely saved from requiring a transfusion. The relationship between the iron status and blood transfusion requirement was not statistically significant.

Discussion: The incidence of preoperative anaemia is significant in patients undergoing THA. Ferrous sulphate therapy on its own did not reduce the blood transfusion requirement. Non-anaemic patients seem to benefit most with iron supplementation, in terms of avoiding blood transfusion. Combination of early screening, appropriate treatment pre-operatively and strict guidelines may help reduce the incidence of blood transfusion.

Aim: Avascular necrosis of the femoral head is believed to play a role in failure of the femoral component in metal on metal hip resurfacing arthroplasty. The purpose of our study was to determine, prospectively, femoral head perfusion during hip resurfacing arthroplasty in the posterior and anterolateral approaches.

Methods: 20 hip resurfacing arthroplasties were performed in 19 patients between September 2005 and April 2006. Patients were divided into two groups according to approach. An equal number of operations were performed by two different surgeons; one using the extended posterior approach and the other an anterolateral approach. Intravenous cefuroxime was administered in every case following capsulectomy and relocation of the femoral head. After 5 minutes the femoral head was dislocated and prepared as routine for the operation. Bone from the top of the femoral head and reamings were sent for assay to determine the concentration of cefuroxime.

Results: The concentration of cefuroxime in bone was significantly greater when using the anterolateral approach (mean 15.7mg/kg; CI 12.3 to 19.1) compared to the posterior approach (mean 5.6mg/kg, CI 3.5 to 7.8; p< 0.001). In one patient, who had the operation through a posterior approach, cefuroxime was undetectable.

Conclusion: The posterior approach is associated with a significant reduction in the blood supply to the femoral head during hip resurfacing arthroplasty. This may be a cause for avascular necrosis and potential failure of the femoral component in this procedure.

The collarless polished tapered stem (CPT) is a double tapered, cemented femoral component designed for primary hip replacement and as a revision stem for impaction bone grafting. We report outcome at a minimum of 10 years (mean 11 years 1 month).

Of 191 consecutive primary hip replacements in 174 patients, implanted using contemporary cementing techniques, 63 patients died before 10 years (68 hips). None of these stems had been revised or had radiological signs of failure at their last follow-up. Only one patient (two hips) was lost to radiological follow-up, hence complete radiological data was available on 121 hips and clinical follow-up on 123 hips. The fate of all the hips is known.

Survivorship with revision of the femoral component for aseptic loosening as the endpoint was 100%. The Harris hip scores were good or excellent in 75% of the patients with a mean of 86. All the stems subsided vertically within the cement mantle at a mean rate of 0.18mm per year, stabilising to a mean total of 1.95 mm (0.21–24 mm) after a mean of 11 years 1 month. Unlike Exeter stems there was no change in the alignment of the stems. There was excellent preservation of proximal bone and an extremely low (< 2%) incidence of loosening at the cement bone interface.

The study confirms that the CPT subsides within the cement mantle, but without failing. It performs at-least as well as the best stems currently available.

Introduction: The collarless polished tapered stem (CPT) is a double tapered cemented femoral component designed for primary hip replacement and as a revision stem for impaction bone grafting. We report the outcome at a minimum of 10 years (mean 11 years 1 month).

Methods and patients: Of 191 consecutive primary hip replacements in 174 patients, implanted using contemporary cementing techniques, 63 patients died before 10 years (68 hips). None of these stems had been revised or had radiological signs of failure at their last follow-up. Only 1 patient (2 hips) was lost to radiological follow-up, hence complete radiological data was available on 121 hips and clinical follow-up on 123 hips. The fate of all the hips is known.

Results: Survivorship with revision of the femoral component for aseptic loosening as the endpoint was 100%. The Harris hip scores were good or excellent in 75% of the patients with a mean of 86 (from 39). All the stems subsided vertically within the cement mantle at a mean rate of 0.18mm per year, stabilising to a mean total of 1.95mm (0.21–24mm) after a mean of 11 years 1 month. Unlike Exeter stems there was no change in the alignment of the stems. There was excellent preservation of proximal bone and an extremely low (< 2%) incidence of loosening at the cement bone interface.

Discussion: The study confirms that the CPT subsides within the cement mantle, but without failing. It performs at least as well as the best stems currently available.