We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared

The clinical results of the cemented Exeter stem in primary hip surgery have been excellent. The Exeter ‘philosophy’ has also been extended into the treatment of displaced intracapsular hip fractures with ‘cemented bipolars’ and the Exeter Trauma Stem (Howmedica). We have identified an increase in the number of periprosthetic fractures that we see around the Exeter stem. We have also identified a particular group of patients with comminuted fractures around ‘well fixed’ Exeter stems after primary hip surgery that present a particular difficult clinical problem. Prior to fracture, the stems are not loose, the cement mantle remains sound and bone quality surrounding the reconstruction is good, i.e. classifying it as a Vancouver B1. However the comminuted nature of the fracture makes reduction and fixation with traditional methods difficult. Therefore in these particular circumstances it is often better to manage these as B2 or even B3 fractures, with distal bypass and uncemented reconstruction. Over an eleven-year period since 1999, 185 patients have been admitted to Nottingham University Hospitals with a periprosthetic femoral fracture around a hip replacement. These patients were identified from a prospective database of all trauma patients admitted to the institution. Of these patients we have identified a cohort of 21 patients (11%) with a periprosthetic fracture around an Exeter polished stem. Hospital notes were independently reviewed and data retrieved. Outcome data was collected with end points of fracture union, re-revision surgery and death. Data was also collected on immediate and long term post-operative complications. The mean age was 76 years at time of fracture, and 52% were male. The mean duration between primary index surgery and fracture was 18 months (median 11 months). 15 patients were classified as Vancouver B1, and six as B2 fractures. Of the B1 fractures, 14 underwent fixation and one was treated non-operatively. Of the B2 fractures, four were revised, one was revised and fixed using a plate, and one was fixed using a double-plating technique. Prior to fracture, none of the implants were deemed loose although one patient was under review of a stress fracture which subsequently displaced. One patient died prior to fracture union. All the other patients subsequently went onto unite at a mean of 4 months. There were no deep infections, non- or malunions. No patient underwent further surgery. Dislocation occurred in one patient and a superficial wound infection occurred in one patient which responded to antibiotic treatment. Three other patients have subsequently died at seven, twelve and fifty-three months post fracture due to unrelated causes. In our series of patients, in addition to the more standard fracture patterns, we have identified a very much more comminuted fracture. Indeed, we have described the appearance as if the tapered stem behaves like an axe, splitting the proximal femur as a consequence of a direct axial load. As a consequence of the injury, the cement mantle itself is severely disrupted. There is significant comminution and soft tissue stripping, calling into question the viability of the residual fragments. Treatment of this type of fracture using a combination of plates, screws and cables is unlikely to provide a sufficiently sound reconstruction. In our experience we believe these fractures around previously ‘well fixed’ Exeter stems should be treated as B2/B3 injuries

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known. At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others. Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Aim. The aim of this study was to determine the medium term survivorship and function of the Exeter Universal Hip Replacement when used in younger patients, a group that is deemed to place high demands on their arthroplasties. Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 130 Exeter Universal total hip replacements (THR) in 107 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. Mean age at surgery was 42 years (range 17-50 years.) Six patients who had 7 THRs had died, leaving 123 THRs for review. Patients were reviewed at an average of 12.5 years (range 10-17 years). No patient was lost to follow-up. Results. At review, 12 hips had been revised. Of these, 9 were for aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation. One femoral component required revision in 1 case of infection. Radiographs showed that a further 11 (10%) of the remaining acetabular prostheses were loose but that no femoral components were loose. Survivorship of stem and cup from all causes was 94%, at an average of 12.5 years. Survivorship of stem only from all causes was 99% and from aseptic loosening was 100%. Conclusion. The Exeter Universal Stem is shown to perform extremely well in the younger patient. No femoral component became loose and only 9 acetabular components were revised for aseptic loosening

There has been much discussion and controversy in the media recently regarding metal toxicity following large head metal on metal (MoM) total hip replacement (THR). Patients have been reported as having hugely elevated levels of metal ions with, at times, devastating systemic, neurolgical and/or orthopaedic sequelae. However, no direct correlation between metal ion level and severity of metallosis has yet been defined. Normative levels of metal ions in well functioning, non Cobalt-Chrome hips have also not been defined to date. The Exeter total hip replacement contains no Cobalt-Chrome (Co-Cr) as it is made entirely from stainless steel. However, small levels of these metals may be present in the modular head of the prosthesis, and their effect on metal ion levels in the well functioning patient has not been investigated. We proposed to define the “normal” levels of metal ions detected by blood test in 20 well functioning patients at a minimum 1 year post primary Exeter total hip replacement, where the patient had had only one joint replaced. Presently, accepted normal levels of blood Chromium are 10–100 nmol/L and plasma Cobalt are 0–20 nmol/L. The UK Modern Humanities Research Association (MHRA) has suggested that levels of either Cobalt or Chromium above 7 ppb (equivalent to 135 nmol/L for Chromium and 120 nmol/L for Cobalt) may be significant. Below this level it is indicated that significant soft tissue reaction and tissue damage is less likely and the risk of implant failure is reduced. Hips were a mixture of cemented and hybrid procedures performed by two experienced orthopaedic consultants. Seventy percent were female, with a mixture of head sizes used. In our cohort, there were no cases where the blood Chromium levels were above the normal range, and in more than 70% of cases, levels were below recordable levels. There were also no cases of elevated plasma Cobalt levels, and in 35% of cases, levels were negligible. We conclude that the implantation with an Exeter total hip replacement does not lead to elevation of blood metal ion levels

Purpose. We describe an update of our experience with the implantation of the first 325 Exeter Universal hips. The fate of every implant is known. Methods and results. The first 325 Exeter Universal stems (309 patients) were inserted between March 1988 and February 1990. The procedures were undertaken by surgeons of widely differing experience. Clinical and radiological review was performed at a mean of 15.7 years. At last review 185 patients had died (191 hips). 103 hips remain in situ. Survivorship at 17 years with revision for femoral component aseptic loosening was 100% (95% CI 97 to 100), with revision for acetabular component aseptic loosening was 90.4% (95% CI 83.1 to 94.7) and with any re-operation as the endpoint was 81.1% (95% CI 72.5 to 89.7). 12 patients (12 hips) were not able to attend for review due to infirmity or emigration, and scores were obtained by phone (x-rays were obtained in 4 patients). Mean D'Aubigné and Postel scores (Charnley modification) at review were 5.4 for pain and 4.8 for function. The mean Oxford score was 21.6 +/− 9.8 and the mean Harris score 71.7 +/− 19.7. On radiological review there were no femoral component failures. Three sockets (2.9%) were loose as demonstrated by migration or change in orientation (two patients were asymptomatic) and 5 sockets (4.9%) had radiolucent lines in all 3 zones but no migration. There are two patients awaiting socket revision. Conclusion. The high rate of clinical and radiological success of the Exeter Universal stem seen at 12 years is sustained at 17 years. Further cup failures have occurred but overall survivorship remains good. With the favourable long-term behaviour of the original Exeter stem, we feel optimistic that good function of the Universal stem will continue through the third decade

We reviewed 142 consecutive primary hip arthroplasties using the Exeter Universal femoral stem implanted between 1988 and 1993 into 123 patients. 74 patients with 88 hips survived to 10 years or more and were reviewed with a mean 12 years 8 months. There was no loss to follow-up and the fate of all stems is known. Our stem revision rate for aseptic loosening and osteolysis was 1.1% (1 stem); stem revision for any cause was 2.2% (2 stems); and re-operation for any cause was 21.6% (19 hips), all but 2 of which were due to cup failure. All but one stem subsided within the cement mantle to an average of 1.5mm at final follow-up (0 to 8mm). One stem was revised for deep infection and one was revised for excessive periarticular osteolysis. One further stem had subsided excessively (8mm) and demonstrated lucent lines at the stem-cement and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. 28% of stems had cement mantle defects, which were associated with increased subsidence (p=0.01), but were not associated with endosteal lysis or stem failure. Periarticular osteolysis was significantly related with the degree of polyethylene wear (p<0.001), which was in turn associated with younger age patients (p=0.01) and males (p<0.001). The Exeter metal backed cups were a catastrophic failure with 34% revised (11 cups) for loosening. The Harris Galante cups failed with excessive wear and osteolysis, with failure to revision of 18%. Only 1 cemented Elite cup was revised for loosening and osteolysis (4%). The Exeter Universal stem implanted outside the originator centre has excellent medium term results

Introduction. Despite being from different manufacturers, Exeter stem and Ogee cup are commonly used together as cemented ‘cross breed’ combination in United Kingdom. The purpose of this study was to evaluate the long-term outcome of this combination. Materials and methods. The ten years outcome of 131 primary hip replacements using an Exeter stem and an Ogee cup combination were studied retrospectively from clinical audit data and radiographs. Results. The Harris Hip score (HHS) improved significantly from 46 pre-surgery to 88 post-surgery. This had a gradual decrease to 81 over ten years. This effect was associated with a decrease in function score but a sustained pain score. Radiologically, five cups were loose and two stems had failed. One stem had migrated and another had progressive endosteolysis. There were two recurrent dislocations, of which one was revised to a bipolar socket. The ten year survival of the combination implant was 99% (CI 97 to 100) with revision as an end point. The same with impending failure as end point was 93% (CI 87 to 99). Conclusion. It might be preferable to have a multi-centric prospective study to demonstrate the performance of this commonly done combination implant at various settings. In the meantime it is concluded that the Exeter stem-Ogee cup combination arthroplasty has acceptable outcomes at ten years

Introduction. Surgical experience has been shown to improve the clinical outcomes in Total hip arthroplasty. The objective of this study was to compare clinical and radiological outcomes between Consultants and NCHDs grade surgeons for the Exeter total hip replacement taken from the Cappagh National Orthopaedic Hospital Joint Register. Methods & Materials. Between 2005 and 2008, 2749 primary total hip replacements were done, 433(15.78%) were Exeter total hip system. 380(86%) out of 433 were included in the study, 227(59%) were females and 154(41%) were males. A consultant was the primary surgeon for 193(51%) patients and an NCHD was the primary surgeon for 187(49%) patients. Mean age, at time of operation was 68 years. Clinical outcome was assessed with WOMAC and SF36 scoring system. Patients were invited to fill in the WOMAC and SF36 questionnaire, pre-operatively, at 6 months and at 2 years after the operation. Radiographs were evaluated for radiolucency with a standardized technique. Results. Mean WOMAC scores for consultant grade surgeons were: 61(pre op), 23.34(6 months post op) and 22.96(at 2 years post op) with standard deviations of 15.61(pre-op), 17.9(at 6 months) and 17.19(at 2 years). Average SF36 scores were 42.40(pre-op), 70.15(at 6 months) and 71.30(at 2 years) with standard deviations of 17.94(pre op), 18.02(6 months) and 22.59(2 years). NCHD grade surgeons had average WOMAC scores: 62.55(pre op), 22.36(6 months) and 25.35(2 years). Average SF36 scores were: 41.1(pre-op), 67.47(6 months) and 66.63(2 years). The difference in the mean WOMAC scores between consultants grade and NCHD grade surgeons were 1.55(pre-op), 0.98(6months) and 2.39(2 years), while the difference between the mean SF36 were 1.3(pre-op), 2.68(6 months) and 4.67(2 years). Student T Test was used to correlate differences between the 2 groups. The difference in outcomes between the 2 groups was not significant (P<0.05). Conclusion. We found out that both groups had similar outcome and survival, with no significant difference when using an Exeter Total Hip Arthroplasty

Background. Since 1991 to 2008 approximately 800,000 Exeter stems have been sold worldwide with 80 reported cases of fracture (neck or stem). This study aimed to determine factors predisposing to fracture. Method. Clinical, surgical, radiological and retrieval data was collated from Stryker Benoist-Girard and Exeter research databases. Risk factors associated with fracture were categorised to patient related (weight and activity levels), surgical related (poor medial support, component size, placement) and implant related (+ head). Results. Data was available on 60 patients (28 stem, 32 neck fractures). Number of fractures per annum increased in proportion with sales. Mean patient age at fracture was similar for both neck and stem fractures (69yrs, 53–84; 67yrs, 30–89. p=0.56). 77% neck and 52% stem fractures occurred in males. Mean weight was 110kg (82–140) in neck and 91kg (70–126) in stem fractures with 68% neck and 38% stem fractures either obese or morbidly obese. Mean time to fracture was 78mths (36–144) for neck and 76 mths (2–155) for stem fractures. 76% of neck fractures occurred in stem sizes 44#2, 44#3 and 44¢4. Stem fractures occurred more commonly (85%) in the smaller sizes (35.5 to 44#1). A + head was used in 67% neck and 14% of stem fractures. Neck fractures were most commonly associated with patient (increased weight and activity) and implant related (use of a + head) factors. Stem fractures were most commonly associated with correctable surgical related causes predominantly secondary to stem undersizing or inadequate medial support. Conclusion. Careful pre operative planning and templating is essential to identify those patients with pre-existing identifiable patient (weight, activity levels) and anatomical (proximal femoral canal morphology and offset) risk factors, to ensure appropriate stem selection and size (which may require a custom made implant) and meticulous placement and cementing technique in order to maximise fracture prevention

Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH. The objective was to perform a prospective evaluation of SDTSO with Cemented Exeter Femoral Component. 15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years were followed-up for a mean of 77 months (11 to 133). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient was lost to follow-up. Charnley-d'Aubigné-Postel scores for pain, function and range of movement were improved from a mean of 2, 2, 3 to 5, 4, 5 respectively. One osteotomy failed to unite at 14 months and was revised successfully. Clinical healing was achieved at a mean of 6 months and radiological at a mean of 9 months. The mean length of the excised segment was 3cm and the mean true limb lengthening was 2cm. A 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting was performed in all cases. Mean subsidence was 1mm and no stem was found loose at the latest follow-up. No sciatic nerve palsy was observed and no dislocation. Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with SDTSO. Transverse osteotomy is necessary to achieve derotation and reduction can be maintained with a DCP plate. Intramedullary autografting prevents cement interposition at the osteotomy site

Implant choice was changed from cemented Thompson to Exeter Trauma Stem (ETS) for treatment of displaced intra-capsular neck of femur fractures in University Hospital Aintree, Liverpool, United Kingdom (a major trauma center), following the NICE guidelines that advised about the use of a proven femoral stem design rather than Austin Moore or Thompson stems for hemiarthroplasties. The aim of our study was to compare the results of Thompson versus ETS hemiarthroplasty in Aintree. We initially compared 100 Thompson hemiarthroplasties that were performed before the start of ETS use, with 100 ETS hemiarthroplasties. There was no statistically significant difference between the two groups in terms of patients' demographics (age, sex and ASA grade), intra-operative difficulties/complications, post op medical complications, blood transfusion, in-patient stay and dislocations. The operative time was statistically significantly longer in the ETS group (p= .0067). Worryingly, the 30 days mortality in ETS group was more than three times higher in ETS group (5 in Thompson group versus 16 in ETS group. P= .011). To corroborate our above findings we studied 100 more consecutive patients that had ETS hemiarthroplasty. The results of this group showed 30 day mortality of 8 percent. However the operative time was again significantly longer (p= .003) and there was 18 percent conversion to bipolar hemiarthropalsty. Moreover there was statistically significant increased rate of deep infection (7%, p = .03) and blood transfusion (27%, p = .007). This we feel may be due to longer and more surgically demanding operative technique including pressurised cementation in some patients with significant medical comorbidities. Our results raise the question whether ETS hemiarthoplasty implant is a good implant choice for neck of femur fracture patients. Randomised control trials are needed to prove that ETS implant is any better than Thompson hemiarthroplasty implants in this group of patients

Aims. We investigated the local epidemiology of Developmental Dysplasia of the Hip (DDH), in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening. Methods. Data were recorded prospectively on all live births in the Exeter area from January 1998 to December 2008. We compared those treated for DDH with all other children. Crude odds ratios (OR) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables. Results. There were 182 children with DDH (245 hips) and 37,051 without. The incidence was thus 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% CI 4.6-11.2), breech presentation (adjusted OR 24.3, 13.1-44.9), positive family history (adjusted OR 15.9, 11.0-22.9) and first or second pregnancy (adjusted OR 1.8, 1.5-2.3) were confirmed as risk factors (p<0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6-4.5, p<0.001) and postmaturity (OR 1.7, 1.2-2.4, p<0.002). Conclusions. One in 200 children born in our area requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child's risk. Our work may contribute to the debate about selective versus universal ultrasound screening

The Exeter stem is a polished cemented stem that has been associated with an excellent survivorship. However, this wedge shaped stem has also been associated with a relative higher risk for a peri-periprosthetic fracture due to the wedge-shaped configuration that can lead to a Vancouver type B2 fracture when the stem is being driven downwards inside the femoral canal by a traumatic blast. Traditionally, these fractures should be treated with a revision stem because the stem has become loosened in the fractured cement mantle. We present a case series of 5 cases where our treatment algorithm was to first let the non-displaced fracture to consolidate by 6 weeks of limited weight bearing as tolerated in order to conduct a second stage in-cement revision. This would simplify the revision procedure dramatically. However, all patients are currently pain free and do not require revision surgery although they are being monitored very closely. We conclude that non-displaced Vancouver type B2 fractures can be approached by a 2 stage treatment algorithm where the initial step is to let the fracture consolidate with limited weight bearing

Recent NICE guidelines have suggested abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem (ETS). This is controversial because of significant cost implications and limited research assessing outcomes of the ETS. The aim of this study was to assess the treatment of intracapsular neck of femur fractures with the TH. Between 2002 and 2006 (minimum 5 year follow-up), 431 cemented TH's were performed. Death rate at 1 year and 5 years were 26.0% and 67.7% respectively. Dislocation (1.4%) and infection (0.2%) rates were low and revision rate was 1.2%. Comparison was made to Bipolar hemiarthroplasties over the same period (total 194). These had lower rates of dislocation (0.5%) and infection (0.5%) with a significantly higher (3.6%) revision rate. We feel that the TH remains the current gold standard treatment for intracapsular fractures, in appropriate patients, due to low complication and revision rates. Modern implants may provide better function or longevity, but there is no evidence in the literature to support abandoning the TH. Surgeons should assess patients and decide on its use, despite NICE guidelines, as it remains a cost effective treatment method, particularly for older, less mobile and cognitively impaired patients

Background

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker)

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker)

Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3-72) months with the average age of patients being 61(range 22-89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire.

46 patients(83.6%) achieved union at a mean time of 3.7 months. 8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative (VAS) score of 1.9(p<0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively.

This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief.

There are longstanding debates regarding surgical versus conservative management of Achilles tendon ruptures, however there is limited focus on rehabilitation. A specific rehabilitation programme was initiated in 2008 to unify management and improve patient outcomes. We present the results at three and a half years.

In October 2008 management was streamlined under the foot and ankle surgeons and a dedicated physiotherapy service. Operative management used mainly the Achillon device (Integra) and VACOped boot with a specific rehabilitation protocol.

We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears).

Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE's (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure.

The authors experience has been that using the VACOped boot with our custom rehabilitation programme in dedicated physiotherapy clinics has produced excellent results.

Multiple joint registries have reported better implant survival for patients aged >75 years undergoing total hip arthroplasty (THA) with cemented implant combinations when compared to hybrid or uncemented implant combinations. However, there is considerable variation within these broad implant categories, and it has therefore been suggested that specific implant combinations should be compared. We analysed the most common contemporary uncemented (Corail/Pinnacle), hybrid (Exeter V40/Trident) and cemented (Exeter V40/Exeter X3) implant combinations in the New Zealand Joint Registry (NZJR) for patients aged >75 years. All THAs performed using the selected implants in the NZJR for patients aged >75 years between 1999 and 2018 were included. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were recorded. 5427 THAs were included. There were 1105 implantations in the uncemented implant combination group, 3040 in the hybrid implant combination group and 1282 in the cemented implant combination group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the cemented implant combination (0.31 revisions/100 component years) and the hybrid implant combination (0.40 revisions/100 component years) but were statistically significantly higher in the uncemented implant combination (0.80/100 component years). Femoral-sided revisions were significantly greater in the uncemented implant combination group. The cemented implant and hybrid implant combinations provide equivalent survival and functional outcomes in patients aged over 75 years. Caution is advised if considering use of the uncemented implant combination in this age group, predominantly due to a higher risk of femoral sided revisions. The authors recommend comparison of individual implants rather than broad categories of implants

The philosophy of cemented total hip arthroplasty (THA) femoral components has become polarised. At one extreme are polished, collarless, tapered devices that are expected to subside; at the other extreme are roughened, non-tapered implants with a collar designed not to subside. Radiostereometric analysis (RSA) allows the accurate measurement of implant movement and has been extensively used for measurement of the in vivo migration of implants. The degree of migration as measured by RSA during the first years after surgery has been shown to correlate with the long-term performance of cemented femoral implants. The purpose of this study was to review the two-year RSA results of two different designs of primary cemented THA stems. Data from two previous prospective RSA trials with two-year follow-up were pooled. The first group included 36 patients who received a Spectron (Smith & Nephew, Memphis, USA) cemented stem. The second group included 13 patients who received an Exeter (Stryker, Mahwah, USA) cemented stem, and 15 patients who received a CPCS (Smith & Nephew, Memphis, USA) cemented stem. All patients underwent RSA examinations shortly post-operation, at 6 weeks, 3 months, 6 months, 1 years, and 2 years. Migration and rotation of the femoral stems was measured at each time point relative to the post-operative exam, and compared between the two groups. There was no difference in age at surgery (Spectron 78 ± 6 years, Exeter/CPCS 77 ± 5 years, p = 0.43), BMI (Spectron and Exeter/CPCS 28 ± 5 kg/m2, p = 0.92), or percentage of male patients (Spectron 23% male, Exeter/CPCS 21% male) between the implant groups. Subsidence was significantly greater (p < 0.0001) at all time points from three months to two years for the Exeter and CPCS stems (0.94 ± 0.39 mm at two years) compared to the Spectron stem (0.05 ± 0.16 mm at two years). There was no significant difference between the stem types for medial-lateral translation (p = 0.07) or anterior-posterior translation (p = 0.49), or for anterior-posterior tilt (p = 0.15), internal-external rotation (p = 0.89), or varus-valgus rotation (p = 0.05). Implant material, design, and surface finish are all factors in the long-term performance of cemented femoral hip implants. In this study, both femoral stem designs had a magnitude of sub-sidence that was within the limits of what is considered to be safe with respect to long-term performance. The continuous subsidence of the Exeter and CPCS stems is consistent with previous reports in the literature