We prospectively investigated a consecutive series of ten patients undergoing a cemented primary total hip replacement (THR) for osteoarthritis in order to establish the elution characteristics of Simplex-tobramycin bone cement (Howmedica, Limerick, Ireland). Specimens of blood, urine and drainage fluid were collected for 72 hours postoperatively. Very high concentrations of tobramycin were found in the drainage fluid, with mean levels at one hour of 103 mg/l, which steadily declined to 15.1 mg/l after 48 hours. The mean serum tobramycin levels reached a peak of 0.94 mg/l at three hours and declined rapidly to 0.2 mg/l by 48 hours. The mean urinary tobramycin levels peaked at 57.8 mg/l at 12 hours with a rapid decline to 12.6 mg/l by 24 hours.

There was a direct correlation between the amount of tobramycin bone cement which was implanted and the amount of tobramycin systemically absorbed. Excellent local delivery was achieved with minimal systemic concentrations. Simplex-tobramycin bone cement is an efficient and safe method for the delivery of antibiotics after THR.

Introduction: The aim of this study was to compare the serum cobalt and chromium levels in patients with Oxford Universal hips and Cenator hips. Both systems are composed of cobalt chromium alloy and have modular cobalt chromium heads, however only the Oxford hip has a sliding mechanism.

Material: The serum levels of chromium and cobalt were measured in 20 patients with Oxford Universal Hip replacement (Group 1). This was compared to the serum levels of chromium and cobalt in 17 patients with Cenator Hip replacement (Group 2) and 20 patients with no implants (Group 3). Patients in Group 1 and 2 were assessed clinically and with plain radiographs. Patients were excluded if there was evidence of loosening, if they had other joint implants or any other known cobalt or chromium implant and if they had impaired renal function. All hip replacements were performed as primary procedures. Specimens were analysed by electrothermal atomization atomic absorption spectrometry.

Results: There was no statistically significant difference in serum cobalt and chromium levels between groups 1 and 2. Patients in groups 1 and 2 had statistically significant higher serum levels of chromium and cobalt than group 3 patients.

Discussion: This study demonstrates that serum levels of chromium and cobalt are elevated in patients with stable hip implants composed of this alloy but not in a normal population. Although it is not known what the long-term effects of chronic low-grade exposure to these ions are, these levels are many order of magnitude below the toxic range. Furthermore, our results show that the Oxford Universal Hip releases no more metal ions into the circulation than an implant without a sliding mechanism.

Purpose: The purpose of the study is to compare the disease severity at the time of surgical intervention between patients undergoing primary joint replacement under the National Health Service and Private Health-care Systems.

Materials: 166 patients were included in the study – 101 NHS and 65 Private. Inclusion criteria were: 1) hip or knee osteoarthritis, 2) primary joint replacement, and 3) informed consent of the patient. Patients with arthropathy of inflammatory, infectious or neoplastic aetiology were excluded. Physician evaluation included medical history, calculation of Charleson Comorbidity Scores, and Knee Society rating. Patients were given self-assessment health questionnaires including WOMAC, SF-36, and Nottingham Health Profile.

Results: Mean age was 69.4 years and did not vary significantly between NHS and Private groups. Charleson Comorbidity Scores were significantly worse in the NHS group than in the private. Health assessment questionnaire scores were all adjusted for age, sex, and comorbidity. In NHS patients undergoing TKR, we demonstrate significantly worse pre-operative comorbidity than in private group for indices of function and pain. Patients undergoing THR showed little difference in pre-operative comorbidity.

Conclusion: NHS patients undergoing primary TKR have significantly more advanced disease than their counterparts who are privately insured. Access to TKR surgery is determined by the healthcare delivery system rather then a threshold level of disease severity. Further follow-up of the outcomes of TKR in these two groups needs to be carried out to determine the long-term effects of accessing surgical care at a more advanced stage of disease.

Temporary immobilisation of joints can lead to permanent ankylosis or fusion. The aim of this study is to demonstrate that treatment of vertebral fractures by single level fusion and 2 level fixation preserves movement in the unfused lower motion segment after removal of metalwork.

12 consecutive thoracolumbar fractures were treated by posterior fixation over two motion segments with fusion of the upper injured segment. Average age 39 years (27–50yrs.) and 6 were male. L2 was most frequently affected (6) then T12 (3), L1(2) and L3(1). Using the Denis classification 9 were Burst type B, 1 was Burst type A and 2 were Compression type B. No patients had abnormal neurology or any other vertebral injury. All operations were performed by one surgeon (RC) within 7 days of injury. Metalwork bridging the injured vertebra was removed at mean 11 months (8–13 * one patient 27 months) and average follow up in this study was 12 months (2–40) after removal of metalwork. A simple pain questionnaire and flexion-extension radiographs were obtained. The average movement in the motion segment previously bridged by metalwork was 5 degrees (0–12). For comparison, the level below moved an average of 7 degrees (2–17). Kyphus angle was 11 degrees (1–18) on presentation corrected to 0 degrees at operation (−6 - +12) returning 1 year after removal of metalwork to 5 degrees (1–16). Pain scores (0–10) were measured retrospectively, prior to the accident mean 0(0–1) and at review 2.6 (0–6).

Only one patient failed to return to previous employment. She had the highest pain score at 6, showed no movement at the bridged motion segment where removal of metalwork was delayed to 27 months.

Introduction: Octacol F15 is a fibrin sealant, derived from human cryoprecipitate, which can be delivered as a spray that seals on contact. Pre-clinical studies have established its safety. The aim of this study was to determine the impact of Octacol F15 on blood loss in patients undergoing THR

Materials and Methods: The effect of Octacol F15 on 81 patients undergoing THR was studied in a randomised, prospective, multi-centres study. 38 patients received Octacol F15 delivered to the soft tissues around the hip at 3 predetermined times throughout the operation. 43 patients received a routine THR. Surgeons were constrained to use their predetermined approach, fixation method, and DVT prophylaxis. Blood loss was measured and transfusion needs recorded along with all adverse events.

Results: Mean blood loss in treatment patients was 699ml v 837ml in controls. Log transformed means adjusted for weight, surgeon and pre-operative haemoglobin showed a significant reduction in blood loss of 197ml or 23.5% (95% CI 5.4% to 38.1%) as an effect of treatment (p=0.014). Intra-operative blood loss was not significantly less in the treatment group (p=0.13) but post-operative blood loss was significantly reduced (p=0.0005). 11 treatment patients received blood transfusions (29%) against 18 controls (42%). This difference in transfusion needs was not significant (p=0.11). There was only one minor complication ‘possibly’ related to the use of Octacol F15.

Conclusion: Octacol F15 significantly reduces blood loss in THR without any increase in the complication rate. Its use in THR, particularly in procedures in which increased bleeding may be encountered, offers important clinical benefits.

We determined the outcome of 56 ‘Oxford’ unicompartmental replacements performed for anteromedial osteoarthritis of the knee between 1982 and 1987. Of these, 24 were in patients who had died without revision, one was lost to follow-up and two had been revised. Of the remaining 29 knees, 26 were examined clinically and radiologically, two were only examined clinically and one patient was contacted by telephone. The mean age of the patients was 80.3 years.

At a mean follow-up of 11.4 years (10 to 14) the measurements of the knee score, range of movement and degree of deformity were not significantly different from those made one to two years after operation, except that the range of flexion had improved. Comparison of fluoroscopically-controlled radiographs at a similar interval of time showed no change in the appearance of the lateral compartments. The retained articular cartilage continued to function for ten or more years which suggests that anteromedial osteoarthritis may be considered as a focal disorder of the knee. This justifies continued efforts to develop methods of treatment which preserve intact joint structures.

We reviewed histologically the incidence and pathogenesis of the deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the pseudocapsule, femoral and acetabular membranes and periprosthetic tissue at revision of 789 cases of failed total hip replacement. In 13, periprosthetic tissues were found to have deposits of CPPD crystals in areas of cartilaginous metaplasia; four also showed evidence of localised deposition of amyloid. None of the patients had a history of chondrocalcinosis in the hip or other joints. Cartilaginous metaplasia and other changes in periprosthetic tissues may predispose to the deposition of CPPD and associated localised amyloid.

We present a case in which the growth of an intraosseous cyst arising from the proximal tibiofibular joint appeared to have been increased by polyethylene wear particles from a medial unicompartmental knee replacement. Histological examination of the cyst wall showed a histiocytic response associated with numerous polyethylene wear particles. This case demonstrates that there is a direct communication between the joint cavity and the cyst. Such communication is probably through openings in the articular cartilage large enough to allow the passage of these particles.