The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility.

We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening.

A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft.

The results of treatment of Lisfranc injuries are often unsatisfactory. This retrospective study investigated 46 patients with isolated Lisfranc injuries at a minimum of two years after surgery. Thirteen patients had a poor outcome and had to change employment, or were unable to find work as a result of this injury. The presence of a compensation claim (p = 0.02) and a delay in diagnosis of more than six months were associated with a poor outcome (p = 0.01). There was no association between poor functional outcome and age, gender, mechanism of injury or previous occupation. This study may have medico-legal implications on reporting the prognosis for such injuries, and highlights the importance of prompt diagnosis and treatment.

We used prospective data from 862 total knee and 716 total hip replacements three years after surgery in order to derive and validate a reduced Western Ontario and McMasters University Osteoarthritis Index (WOMAC) function scale. The reduced scale was derived using the advice of clinical experts as well as analysis of data. The scale was tested for validity, reliability and responsiveness.

Items which were retained included: ascending stairs, rising from sitting, walking on the flat, getting in or out of a car, putting on socks, rising from bed, and sitting.

The reduced and full scales had comparable, moderate correlations with other measures of function, confirming convergent validity. Cronbach’s alpha was high (α > 0.85) with the reduced scale confirming reliability. Responsiveness was greater for the reduced scale (full = 1.4, reduced = 1.6).

This reduced version of the WOMAC function scale provides a practical, valid, reliable and responsive alternative to the full function scale for use after total joint replacement. Further work is needed to demonstrate its wider applicability.

Purpose: To compare the ten-year survivorship results of an established total and medial compartment knee replacement performed in a single centre over an eighteen year period.

Method: Since 1978 knee replacements have been prospectively recorded in Bristol on a database. Regular clinical and radiological review has been undertaken every two or three years up to twenty years. 408 medial St Georg Unicompartmental replacements and 531 Kinematic total knee replacements have been subject to survivorship analysis using three failure end points. One - revision or removal of the implant. Two – revision or removal and moderate or severe pain. Three – the worst case including all patients lost to follow-up.

Results: The follow-up rate was 97% in both groups. 212 patients (562 knees) died and 31 patients (35 knees) were lost to follow-up. At ten years 25 medial Sled and 20 Kinematic knee arthroplasties had been revised. There was no significant difference (p > 0.05) in the number of good and excellent results. The mean range of movement at the last follow-up was 109 degrees for the medial Sled and 100 degrees for the Kinematic (p< 0.01). 94% of the medial Sled patients obtained a range of movement equal to or greater than 90 degrees whereas only 84% of Kinematic patients obtained this range (p < 0.05).

The ten-year survivorship figures were similar for both groups. Revision as the end point was 87.5% for the medial Sled and 89.6% for the Kinematic knees. When moderate and severe pain was considered in addition to revision ten-year survivorship was 79.4% in both groups. The worst case survivorship was also 74% in both groups.

Conclusion: The ten-year survivorship results of a fixed bearing, non-congruous, Unicompartmental arthroplasty are as good as those of a total knee replacement when performed in a single centre by two consultant surgeons and a variety of trainees. The advantages of a more rapid recovery and better quality result are offset by an easier though slightly higher revision rate.

We have studied the long-term outcome of 408 primary medial St George Sled unicompartmental arthroplasties of the knee and 531 primary Kinematic total knee arthroplasties using survivorship analysis. The operations were performed by a number of surgeons under the supervision of two consultants at one orthopaedic centre. Prospective clinical assessment was carried out before and at 2, 5, 8, 10, 12 and 15 years after operation. Failure was defined as follows: revision or removal of the implant; the presence of moderate or severe pain; or ‘worst-case’ with all patients lost to follow-up.

Cumulative survival rates at ten years were calculated using life tables. The follow-up rate was 97%. At ten years, 25 medial sled arthroplasties and 20 Kinematic knee arthroplasties had been revised. With revision or removal as the survivorship endpoint at ten years there was a success rate of 87.5% for the medial sled and 89.6% for the Kinematic knee arthroplasty. When moderate or severe pain was included these rates became 79.4% for both arthroplasties. There was no statistically significant (p > 0.05) difference between the rates of survival for the two arthroplasties using either of the endpoint criteria.

Good or excellent results were recorded for 77.9% of the medial sled knees and 75.1% for the Kinematic knees. The former had 93.8% of cases with a final range of movement in excess of 90° compared with 83.7% for the Kinematic knees (p < 0.01). We conclude that at a single orthopaedic centre in the UK, the St Georg Sled medial compartment arthroplasty for appropriate specific indications offers predictable survivorship at ten years which is comparable with that of the Kinematic total knee arthroplasty.

We describe the results of 76 total arthroplasties of the hip for stage-III or stage-IV avascular necrosis of the femoral head. Harris Galante Porous cups were used in 63 patients between 1986 and 1994 and followed prospectively. We reviewed 70 hips with a follow-up of more than five years (mean 7.6).

At the latest review the mean Harris Hip Score had improved from a preoperative value of 29 ± 14.7 to 94 ± 6.8. Radiologically, there was no evidence of acetabular migration. The rate of revision for the femoral component was 8.6%, three being undertaken for loosening and three to allow downsizing of the femoral head. The rate of revision for the acetabular component was 7.1% (five cups). At the time of revision none of the cups was clinically loose, and only required the liner to be changed.

The rate of complications was low with no case of deep infection or dislocation, but nine of the 76 hips (11.8%) showed grade-III heterotopic ossification. Previous studies of patients undergoing cemented total hip arthroplasty for the treatment of advanced avascular necrosis have indicated a high incidence of loosening of the acetabular component. Our findings show good medium-term results using the Harris Galante Porous cup for acetabular reconstruction, together with a variety of cemented femoral components, for the treatment of this difficult problem.