Introduction: The functional outcome and survivorship of knee arthroplasty in young patients remains a concern. The aim of this study is to assess patient reported outcomes of knee arthroplasty surgery in osteoarthritic patients age 55 years old or younger in a generalist setting.

Patients and methods: All patients 55 years old or younger at the time of index arthroplasty were identified from the Trent arthroplasty register. Demographic data was available for all patients. A self-administered questionnaire was mailed to patients. This questionnaire included an Oxford Knee Score along with questions relating to employment, leisure activities and the patient expectations of their surgery.

Results: 242 patients 55 years old or younger had a knee arthroplasty in the study period (male:female 1:1). 208 patients had a total knee arthroplasty. The remaining had a unicompartmental knee replacement. Mean age of patients for the total knee arthroplasty group was 51 years (range 37–55) and that for the unicompartmental group was 50 years (range 37–55). The average length of follow up for the total knee arthroplasty group was 33.3 months (range 12–57) and that for the unicom-partmental group was 29.3 months (range 16–45). The average Oxford knee score at follow up was comparable between the two groups; 31.8 (range 12–57) for the total knee arthroplasty group and 32.0 (range 13–54) for the unicompartmental group. 77% of patients in the total knee arthroplasty group and 71% of patients in the uni-compartmental group reported that the pain relief was better or just as they expected following the operation.

Conclusion: Knee arthroplasty remains a satisfactory procedure in young patients under the age of 55 years. There is no significant difference in Oxford knee scores between patients that have total knee replacement or unicompart-mental knee replacement. Pain relief is better or just as expected in the majority of patients in both groups.

We report the long-term survival of a prospective randomised consecutive series of 501 primary knee replacements using the press-fit condylar posterior cruciate ligament-retaining prosthesis. Patients received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. Altogether, 44 of 501 knees (8.8%) underwent revision surgery (24 cemented vs 20 cementless). For cemented knees the 15-year survival rate was 80.7% (95% confidence interval (CI) 71.5 to 87.4) and for cementless knees it was 75.3% (95% CI 63.5 to 84.3). There was no significant difference between the two groups (cemented vs cementless; hazard ratio (HR) 0.83, 95% CI 0.45 to 1.52, p = 0.55). When comparing the covariates there was no significant difference in the rates of survival between the side of operation (HR 0.58, p = 0.07), age (HR 0.97, p = 0.10) and diagnosis (HR 1.25 p = 0.72). However, there was a significant gender difference, with males having a higher failure rate with cemented fixation (HR 2.48, p = 0.004). Females had a similar failure rate in both groups.

This single-surgeon series, with no loss to follow-up, provides reliable data of the revision rates of one of the most commonly-used total knee replacements. The survival of the press-fit condylar total knee replacement remained good at 15 years, irrespective of the method of fixation.

This is a 15-year follow-up observational study of 4390 patients with 4606 primary total knee replacements (TKRs) implanted in the Trent health region between 1990 and 1992. The operations were performed in 21 hospitals, including both district general and teaching hospitals, with 77 different surgeons as named consultant.

The main objective was to analyse the survival of the patients and of the prostheses, and to evaluate what impact different variables have on survival. In addition, the 1480 patients (33.7%) (1556 TKRs) alive at 15 years following operation were sent a self-administered questionnaire which examined their level of satisfaction, of pain, and their quality of life at 15 years. Completed responses were received from 912 TKRs (58.6%).

Three survival curves were constructed: a best-case scenario based on the patients entered into the life tables, another included failures not reported in the revision database, and a third worst-case scenario based on all patients lost to follow-up presumed to have had a failed primary TKR. In the best-case scenario survival at 15 years was 92.2%, and in the worst-case scenario was 81.1%. Survival was significantly increased in women and older patients (Mantel-Cox log-rank test, p < 0.005 and p < 0.001, respectively).

Revision as a result of infection was required in 40 TKRs (18.8%) representing 0.87% of the original cohort.

The limited information available from the questionnaire indicated that satisfaction was less frequent among men, patients with osteoarthritis and those who required revision (chi-squared test, p < 0.05, p < 0.05 and p < 0.0001, respectively). With regard to pain, older patients, females and patients who still had their primary replacement in place at 15 years, reported the least pain (chi-squared test for trends, p < 0.0005, p < 0.005 and p < 0.0001, respectively). The reported quality of life was not affected by any variable.

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region.

Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results.

Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year.

Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?

We prospectively randomised 100 patients undergoing cemented total knee replacement to receive either a single deep closed-suction drain or no drain.

The total blood loss was significantly greater in those with a drain (568 ml versus 119 ml, p < 0.01; 95% CI 360 to 520) although those without lost more blood into the dressings (55 ml versus 119 ml, p < 0.01; 95% CI −70 to 10). There was no statistical difference in the postoperative swelling or pain score, or in the incidence of pyrexia, ecchymosis, time at which flexion was regained or the need for manipulation, or in the incidence of infection at a minimum of five years after surgery in the two groups.

We have been unable to provide evidence to support the use of a closed-suction drain in cemented knee arthroplasty. It merely interferes with mobilisation and complicates nursing. Reinfusion drains may, however, prove to be beneficial.

Purpose: To determine the current arthroplasty practice in osteoarthritic patients aged 55yrs or less for the population registered on the Trent & Wales Arthroplasty Database and stimulate debate. Is there a ‘gold standard’? If there is what is it ?

Method: The Trent Arthroplasty Audit Group collects prospective data on all hip arthroplasty surgery performed in Trent Region & North & West Wales (population 6.2 million). In 2000/2001 9.4% of the primary T.H.Rs and 14.1% of the revision T.H.Rs were aged 55yrs or less. We analysed the database to produce the following results.

Results: In 2000/01 385 primary T.H.Rs were performed on patients aged< 55yrs. 52% of the patients were male, the mean age at surgery was 48.3 yrs (Range 30–55yrs). 12% of the patients had a metal on metal hip resurfacing implant. In 39% both the femoral and acetabular components were uncemented. 14% had a hybrid combination. In 36% of cases the femoral and acetabular components were made by different manufacturers.

The bearing surfaces chosen were: metal / metal in 13%, metal on poly in 56%, ceramic on poly in 28% (Zirconia in 7.4%) and ceramic on ceramic in 3%. Low viscosity cement was used with 28% of femoral components and 19% of acetabular components. The predominant femoral head size was 28 mm.(49%) (22mm in 23%).

Conclusion: Surgeons strive to use up-to-date technology in young patients in an attempt to prolong the life of their hip replacement. At the present time we don’t appear to have a clear picture as to what is the ‘gold standard’ for young patients. How much evidence do we need before implanting a new implant or combination?

Purpose: To determine current practice in knee Arthroplasty surgery for osteoarthritis in young patients for the population registered on the Trent and Wales Arthroplasty Database. Is there a ‘gold standard’? If there is what is it?

Method: The Trent Arthroplasty Audit Group collects prospective data on all knee Arthroplasty surgery performed in Trent Region and North and West Wales (population 6.2 million). In 2000/2001 7% of knee arthroplasties were performed on osteoarthritic patients aged 55 years or less. We analysed the database to reach the following results.

Results: In 2000/01 208 arthroplasties were performed in this group of patients. The youngest patient was 36 yrs. Seventy per cent of the patients were aged between 50 and 55 years. 114 were female. 27 had a unicompartmental knee replacement, mobile bearing in 25. Where the patient had a condylar knee replacent a mobile bearing design was implanted in 10 knees. A PCL sacrificing implant was used in 36% of cases. The patella was resurfaced in 31%. An uncemented prosthesis was used in 19 knees. An 8mm tibial insert was implanted in 32 cases and an insert of less than 10mm in a further eight cases. The surgery was performed by a Consultant in 65% of cases. A Consultant assisted in a further 14% of cases. The arthroplasty was the first surgical procedure to the knee in 38% of cases. The arthroplasty followed arthroscopic procedures in a further 41% of cases.

Conclusions: The surgeons of the Trent Arthroplasty Audit Group are offering knee Arthroplasty to their patients at an earlier stage. Surgeons don’t appear to change their surgical practice or choice of implant when operating on young osteoarthritic patients. Given that we have previously shown that 20% of these patients are disappointed by the pain relief and 38% by their level of function what should we recommend?

As part of a prospective study of 476 total knee replacements (TKR), we evaluated the use of manipulation under anaesthesia in 47 knees. Manipulation was considered when intensive physiotherapy failed to increase flexion to more than 80°. The mean time from arthroplasty to manipulation was 11.3 weeks (median 9, range 2 to 41). The mean active flexion before manipulation was 62° (35 to 80). One year later the mean gain was 33° (Wilcoxon signed-rank test, range −5 to 70, 95% CI 28.5 to 38.5). Definite sustained gains in flexion were achieved even when manipulation was performed four or more months after arthroplasty (paired t-test, p < 0.01, CI 8.4 to 31.4).

A further 21 patients who met our criteria for manipulation declined the procedure. Despite continued physiotherapy, there was no significant increase in flexion in their knees. Six weeks to one year after TKR, the mean change was 3.1° (paired t-test, p = 0.23, CI −8.1 to +2).

We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description.

We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.