Introduction

The new era of shoulder arthroplasty is moving away from long stemmed, cemented humeral components to cementless, stemless and metaphyseal fixed implants and to humeral resurfacing. The early clinical results and functional outcome of stemless shoulder arthroplasty is presented.

Introduction

The rapidly expanding aging population in the UK are living longer than ever before, which is reflected by the rising number of relatively fit and healthy people that sustain fracture NOF (neck of femur). According to current NICE (National institute for health clinical excellence) guidelines a large proportion of fracture NOF patients meet the requirements to have a total hip arthroplasty (THA) for this injury. Dislocation rate of THA can be as high as 20% for patients with fracture NOF, which is a disastrous complication in these vulnerable patients. Numerous techniques have been adopted to minimise the risk of dislocation. The use of dual mobility (tripolar) acetabular components is one such strategy with a proven track record in the literature that is employed by surgeons at our institute.

Introduction: Peri-prosthetic osteolysis due to wear has been acknowledged as a major challenge to long-term survival of hip arthroplasty and this has led to a search for alternative articular bearing couples. We present our experience with metal-on-metal (Metasul^®) articulation with a minimum patient follow-up of 5 years.

Materials and methods: 193 patients (215 hips) were reviewed; 187 (209 hips) had a follow-up of ≥ 5 years. Hip scores were completed and radiographs performed at follow-up visits and data was entered prospectively into software (orthocom) designed by Sulzer Ltd.. Serial radiographs were reviewed retrospectively along with hospital notes and the database.

Results: mean age was 70 (± 7.46) years (range 47–86 years). Female: male was 143:44. Most common pre-operative diagnoses were: osteoarthritis (147) and intra-capsular hip fracture (22).

Mean pre-operative HHS was 39.7 (±15.7) and the corresponding pain score was 13.4 (±8.49). The average post-operative scores were 89.5, 87.3, 88.4 and 85.8 at 1 year, 3 years, 5 years and final follow-up respectively. The corresponding pain scores were 42.7, 41.98, 42.1 and 41.94. Implant survival for the cohort as a whole was 95.5% at 12 years (ci: 88%–100%). Survivorship for the Weber Metasul cup was 93.4% at 12 years (ci: 82.7%–100%) and for armor cup was 100% at 11 years.

Complications included: dislocations (7), periprosthetic fractures (8), deep infection- early (3) & late (3), aseptic loosening (cup) (2) & heterotopic ossification (9). There were no untoward systemic complications with regards to metal ion release.

Discussion: We believe that second generation metal-on-metal implants (Metasul^®) with improved design and better lubrication show better survival with regards to aseptic loosening and reduction in osteolysis in the medium-term. Concerns regarding metal ion and metal particle release remain theoretical but are kept under constant review.

Introduction: There has been a renewed interest in metal-on-metal articulation in hip joint Arthroplasty. The reason for having metal-on-metal articulation is to reduce the volume of wear particles that are produced with THR. The outcome of reduced particle formation will hopefully be reduced osteolysis.

Methods: We reviewed the results of 139 primary hip arthroplasties (130 patients) performed using Metasul articulation and cemented Weber cup. Six patients were lost to follow-up leaving 133 hips (124 patients) for review with at least 5-year follow-up. The acetabular socket was the cemented Weber cup and Bone grafting of the acetabulum and application of a reinforcement ring was done where necessary. Cemented CF-30 femoral stem was used in all patients but one (PFMR). The study was conducted retrospectively based on the information collected from hospital notes and Orthocom database. Immediate post-operative films were seen to measure the cup and stem inclination and quality of cementing using the Barracks grading system.

Results: There were 102 females and 22 males in the cohort. Mean age was 73 years (SD-7.46, range 58–86). Left to right hip ratio was 52:81. Most common Pre-operative diagnosis was Osteoarthritis (103) followed by Intracapsular fracture neck of femur (20). The average follow-up was 7.23 years (range 5–10.9). Mean pre-operative Harris hip score was 42.09 and mean post-operative hip scores were 90.01, 86.84, 87.42 and 84.63 at 1-year, 3-year, 5-year and final follow-up with the corresponding pain scores were 42.9, 41.84, 41.56 and 41.56 respectively. Only two hips were revised for aseptic loosening of the cup with a 93.4% implant survivorship at 12 years. There was no case of aseptic stem loosening. No untoward systemic effects were noted in the cohort.

Discussion: We believe that in our study Metasul metal-on-metal articulation has shown satisfactory results with regards to aseptic loosening and reduction in osteolysis in medium-term.

Introduction: Aseptic loosening is the major cause of implant failure. In cemented hip Arthroplasty it is well known that the acetabular side fails earlier due to lysis caused by wear particles. This is the rationale for Hybrid hip Arthroplasty. It might be advantageous to use a bearing which has a low wear rate. The purpose of this study is present the medium term results of this Uncemented cup with a metal-on-metal bearing.

Methods: We reviewed the results of 119 hips (101 patients) who had the Uncemented Fitmore® cup (Sulzer/Zimmer Orthopaedics, Inc). In 66 out of the 101 patients the femoral component used was CF-30® (Sulzer/Zimmer Orthopaedics, Inc) used with cement. In 35 patients Thrust plate prosthesis TPP® (Sulzer/Zimmer Orthopaedics, Inc) was used. This is a bolt type device which is fixed on to the neck; the femoral canal is not violated. Of the 101 patients, 90(108 hips) were available for study. All had minimum of 5 years follow-up.

Results: Mean follow-up of the 90 patients is 87.4 months (range 60 – 129 months). The mean pre-op Harris hip score is 38.2. The mean post-op Harris hip score is 89.6 at the last follow up. Taking aseptic loosening as the end point the survival rate of the Fitmore cup is 100% at 11 years. Four cups were revised for other causes.

Discussion: Histological studies of retrieved metal-on-metal implants have always shown low volume of inflammatory tissue. Wear rate of metal-on-metal hips is 60–100 times lower than metal-on-polyethylene hips. In the medium to long term Uncemented cups fare better than cemented cups. It might be advantageous to use an Uncemented cup with a metal-on-metal bearing. This follow-up study which has a 100% survival rate at 11 years proves that.

Introduction There has been increasing interest and enthusiasm among both surgeons and patients for small incision for total hip joint replacement (THR). We conducted a prospective study to compare the early postoperative recovery following the two different incisions.

Materials and Methods 40 patients were prospectively randomised (20 patients in each group) by use of envelopes to undergo either conventional or minimal incision (MI) approach for THR between Sept. 2003 and Aug. 2004. Patients with BMI (body mass index) ≤ 30 were considered suitable for randomisation. Conventional incision was 12 cm standard posterolateral in all cases and minimal incision was defined as within 2 cm of the diameter of the contralateral uninvolved femoral head. Minimal incision was made over the posterior aspect of the greater trochanter. All procedures were performed by the senior author. The patients were assessed for operative time, blood loss, haematological parameters, wound healing, ease of mobilisation, post-operative pain, hospital stay and complications. The patients, and assessors (physiotherapists and nurses on ward) were unaware of the treatment group.

Results Average age was 66.95 years for MI group and 68.55 for conventional group (p-0.501). Average BMI for MI and conventional group was 26.5 & 24.4 respectively (p-0.029). Average pre-operative Oxford hip score was 41.75 for conventional group and 42.15 for MI group (p-0.87). There was no statistically significant difference as regards the operating times (p-0.207); post-operative day the patients were mobilised with zimmer frame (p-0.71); drop in hemoglobin (p-0.197) and hematocrit (p-0.208) or the need for blood transfusion (p-0.56). However there was a statistically significant difference in the two groups as regards post-operative pain (on a 10 point visual analogue scale) and the number of postoperative days the patient was fit for discharge. Average pain score on day 1 was 4.05 for MI group and 6.25 for conventional group (p-0.0089) with similar difference on day 2 and the day of discharge. Patients in MI group were fit for discharge on an average 1.65 days earlier than those in conventional group (p-0.042). There was no superficial or deep wound infection, dislocation or per-operative fracture in either group. Transient sciatic nerve neuropraxia occurred in one patient in the minimal incision group which recovered within 6 weeks.

Conclusion Minimal incision posterior approach for total hip replacement may be useful in decreasing the post-operative pain and duration of hospital stay. However the incidence of complications is an area of concern and needs to be studied on a larger study group.

Introduction The aim of this study was to assess the comparability of telephone questionnaire interviews with outpatient attendance for assessing hip function after Total Hip Replacement (THR).

Materials and Methods 100 patients attending the orthopaedic clinic for follow-up after undergoing THR were recruited to this study. A modified Harris Hip Score (HHS) was used as the questionnaire. This modified score assessed pain and function with 8 variables and had a maximum score of 91. The score thus obtained was multiplied by a factor of 1.1 to derive a score out of 100. Patients attending follow-up clinics were contacted by telephone between 1–2 weeks prior to their scheduled appointment and the questionnaire was completed. The questionnaires thus completed were compared to those completed in the clinic.

Results The mean HHS obtained with the telephone interview was 85.22 as compared to 86.11 obtained at direct interview with a Pearson’s correlation coefficient of (0.906) and p-value for the difference of (0.111). Out of a total of 800 variables assessed 725 (90.37%) had the same scores by the two methods and only 75 (9.67%) showed a discrepancy. Only 3 patients had a significant difference (more than 20 points) between the two methods.

Conclusion The study shows that there is no significant difference between scores obtained by telephone interview or direct interview using a modified HHS. Telephone interview is an important adjuvant tool for patient follow-up after THR and a useful adjunct to lifelong review.

Introduction: The aim of this study was to assess the feasibility of telephone questionnaire interviews for assessing hip function after Total Hip Replacement (THR).

Methods: 100 patients attending the orthopaedic clinic for follow-up after undergoing THR were recruited to this study. A modified Harris Hip Score (HHS) was used as the questionnaire. This modified score assessed pain and function with 8 variables and had a maximum score of 91. The score thus obtained was multiplied by a factor of 1.1 to derive a score out of 100. Patients attending follow-up clinics were contacted by telephone between 1–2 weeks prior to their scheduled appointment and the questionnaire was completed. The questionnaires thus completed were compared to those completed in the clinic.

Results: The mean HHS obtained with the telephone interview was 85.22 as compared to 86.11 obtained at direct interview with a Pearson’s correlation coefficient of (0.906) and p-value for the difference of (0.111). Out of a total of 800 variables assessed 725 (90.37%) had the same scores by the two methods and only 75 (9.67%) showed a discrepancy. Only 3 patients had a difference of > 20 points between the two methods.

Conclusion: The study shows that there is no significant difference between scores obtained by telephone interview or direct interview using a modified HHS.

Telephone interview is an important tool for patient follow-up after THR and a useful adjunct to life-long review.

The TPP is a bone conserving Total Hip Replacement (THR). Originally designed in 1977, two modifications have been made since then and in its current form has been available since 1981.

We have used the TPP with a metal-on-metal articulation for active “younger” patients. The acetabular component has been the Armor cup.

48 TPPs have been performed in 41 patients since 1995. The age of the patients was 48 (21–54) years at the time of the operation. There were 17 females and 24 male patients. All patients are kept on an annual review. At the last review, one patient (2 THR) had died at eight weeks from a pulmonary embolism; one patient was lost to follow-up; one patient had required a revision for aseptic loosening.

We believe that this THR may offer a viable alternative for the younger patient, though it is a technically demanding procedure.

The Armor cup is a Titanium shell designed to press-fit into the acetabulum. It has 2 additional screw holes for screw fixation. The liner is polyetylene with a metal-on-metal articulation bearing surface.

We have performed 194 Total Hip Replacements (THR) in 167 patients using the Armor cup from 1994 to 2001. 83 THRs were performed using an uncemented stem (46 Thrust Plate Prostheses, 28 Wagner Cones and 15 Zwyemullers) and 111 THRs were carried using the cemented, polished, cannulated CF30 stem. The patient age was 54 (22–77) years at the time of the operation.

All patients are under annual review. At the last review, 3 patients had died (6 THRs); 4 patients required revision – 2 for the CF30 stem where Boneloc cement had been used, 1 for a periprosthetic fracture and 1 for a dislocated Armor cup. 1 patient was lost to follow-up.

We have therefore found the Armor cup with a metal-on-metal articulation to be a satisfactory componenet in the short to medium term. 26 patients are now over 60 months following implantation.

To assess the value of physiotherapy in the treatment of patients with subacromial impingement syndrome

Patients with subacromial impingement syndrome were identified. Those who had not previously had any physiotherapy and had failed to respond to non-surgical management were selected and placed on the waiting list for subacromial decompression.

Patients were randomised into two groups. One group was referred for physiotherapy while waiting for surgery. The control group had no intervention prior to surgery.

The patients in the physiotherapy arm underwent assessment and treatment by a single physiotherapist.

All patients were evaluated independently at 3 and 6 months. The Constant Score was used to assess all patients initially and at each visit.

Physiotherapy group: All patients (n=42) increased their Constant score. 11 of the 42 patients improved to an extent that surgery was no longer required (26%). In patients not requiring surgery, the mean improvement in Constant score was 25 (12–45) In patients requiring surgery (n=31), the mean improvement was 21 (3–34).

Patients not requiring surgery had a higher initial Constant score, 65 (30–84) than those requiring surgery 48 (17–59). Patients not requiring surgery also tended to be younger 52 (27–68) than those requiring surgery 59 (48–68).

Control group: All patients (n=23) went on to have surgery.

The mean improvement in Constant score was 2 (−16 to 12).

All patients with subacromial impingement syndrome improved with physiotherapy when compared to a control group that did not receive physiotherapy. Some patients in the physiotherapy group improved to the extent that surgery was no longer required (26%)

Aim: To assess the value of physiotherapy in the treatment of patients with subacromial impingement syndrome.

Methods: Patients with subacromial impingement syndrome were identified. Those who had not previously had any physiotherapy and had failed to respond to other types of non-surgical management were selected and placed on the waiting list for subacromial decompression. These patients were randomised into two groups. One group was referred for physiotherapy while waiting for surgery. The control group had no intervention prior to surgery. The patients in the physiotherapy group underwent an assessment and treatment by a single physiotherapist. All patients were evaluated independently after each of three and six months. The Constant Score was used to assess all patients initially and at each visit.

Results: Physiotherapy group: All patients (n=42) increased their Constant score. Eleven of the 42 patients (26%) improved to an extent that surgery was no longer required. In patients not requiring surgery, the mean improvement in the Constant score was 25 (range: 12 to 45) In the patients requiring surgery, (n=31), the mean improvement was 21 (range: three to 34). Patients not requiring surgery had a higher initial Constant score, 65 (range: 30–84) than those requiring surgery 48 (range: 17 to 59). Patients not requiring surgery also tended to be younger 52 (range: 27 to 68) than those requiring surgery 59 (range: 48 to 68).

Control Group: All patients (n=23) went on to have surgery. The mean improvement in Constant score was two (Range: −16 to 12).

Conclusions: All patients with subacromial impingement syndrome improved with physiotherapy when compared with a control group that did not receive physiotherapy. Some patients in the physiotherapy group (26%) improved to the extent that surgery was no longer required.

Aim: To study the outcome of the modified Bosworth technique for Tossy III acromio-clavicular joint (ACJ) dislocations

Methods: Thirty-six patients were treated surgically for Tossy III ACJ dislocations over a period of five years.

A modified Bosworth technique was used in all patients. The shoulders were immobilised in collar and cuff slings for six weeks. The screws were removed after six to eight weeks. The patients were assessed using the modified Constant Score. The average follow up was 35.2 months (range: seven to 60 months).

Results: Thirty-five patients were available for follow-up. The average age was 35.5 years (range: 25 to 62 years).

Using the modified Constant score:

– Twenty-six patients (74%) scored 100;

Conclusions: In our experience the modified Bosworth technique has proven to be a reliable method for treating Tossy III dislocations of the ACJ. This has applied to all ages and for both acute and chronic dislocations.

We concluded that this technique produced good to excellent functional results and we would recommend its use for Tossy III ACJ dislocations. The technique is not obsolete!

We have performed 466 metal-on-metal total hip replacements (THR) in our hospital, since November 1993. Forty-seven of these have been the TPP (Thrust plate prosthesis - Sulzer Medica). We present here the results of our experience with this prosthesis when used for the “younger” patient. Forty-two patients received 47 THRs The age was 40 years (range: 21 – 53 years) There were 25 female patients.

At the latest review: one patient (with two THRs) had died from a pulmonary embolus one patient had a revision for an aseptic loosening (one hip) one patient was lost to follow-up (one hip). The remainder were satisfactory although two hips had subsided into a varus position. The early results were satisfactory in this high-demand group of patients.

This retrospective study was carried out to study the outcome of the modified Bosworth technique for Tossy Type III Acromioclavicular Joint (ACJ) dislocation; good or excellent results were obtained in 91% of cases.

Thirty-six patients were operated for Tossy Type III ACJ dislocations over a period of five years. Thirty-five patients were available for follow-up, one was lost to follow-up. All patients were operated upon using a modified Bosworth technique. Through a strap incision medial to the ACJ, the subperiosteal flaps of trapezius and deltoid were raised along the longitudinal axis of the clavicle. The ACJ was reduced and a partially threaded, cancellous, screw with washer was used under vision to lag clavicle to the coracoid process. The shoulder was immobilised in a collar and cuff sling for six weeks. The screw was removed at between six and eight weeks in 94% cases and the shoulder was mobilised. Patients were assessed using the modified Constant Score (muscle power assessed clinically using Medical Research Council’s grading). Thirty-one patients were operated upon acutely (with in an average of eight days), two sub acutely at four and seven weeks and two chronically at 15 and 24 months. The average follow up was 35 months (range: seven to 60 months). The average age was 35 years (range: 25– 62 years).

Using the modified Constant score: 26 patients (74%) scored 100; five patients (14%) scored 90–99 and one patient (3%) scored 87 (against a score of 96 on the other side due to gross obesity). Three patients (9%) scored poorly.

The first patient scored 49 and she needed reinsertion of the screw at two weeks as following a fall the screw loosened and backed out. She underwent a coracoacromial ligament transfer and another lag screw at 12 months. The second patient scored 59; however, this patient was on oxygen therapy, corticosteroid therapy and heparin for asthma. The third patient scored 79 but also suffers from cervical spondylitis and is an intravenous drug abuser.

In our experience the modified Bosworth technique has proven to be a reliable method for treating Tossy III dislocations of the ACJ. This has applied to all ages and both acute and chronic dislocations. We conclude that this technique can produce good to excellent functional results and hence we recommend its use for Tossy Type III ACJ dislocation.

The purpose of this study was to assess the value of physiotherapy in the treatment of patients with subacromial impingement syndrome

Patients with subacromial impingement syndrome were identified. Those who had not previously had any physiotherapy and had failed to respond to non-surgical management were selected and placed on the waiting list for subacromial decompression. Patients were randomised into two groups. One group was referred for physiotherapy while waiting for surgery. The control group had no intervention prior to surgery. The patients in the physiotherapy arm underwent assessment and treatment by a single physiotherapist. All patients were evaluated independently at three and six months. The Constant Score was used to assess all patients initially and at each visit.

For the physiotherapy group, all patients (n=42) increased their Constant score. Eleven of the 42 patients improved to an extent that surgery was no longer required (26%). In patients not requiring surgery, the mean improvement in Constant score was 25 (12–45). In patients requiring surgery (n=31), the mean improvement was 21 (3–34). Patients not requiring surgery had a higher initial Constant score, 65 (30–84) than those requiring surgery 48 (17–59). Patients not requiring surgery also tended to be younger 52 (27–68) than those requiring surgery 59 (48–68).

For the control group, all patients (n=23) went on to have surgery. The mean improvement in Constant score was two (−16 to 12)

All patients with subacromial impingement syndrome improved with physiotherapy when compared to a control group that did not receive physiotherapy. Some patients in the physiotherapy group improved to the extent that surgery was no longer required (26%)

We studied the morphology of the contralateral femur in 10 patients with subcapital fractures, 10 with trochanteric fractures and 10 with unilateral osteoarthritis. We found that the patients with trochanteric fractures had a significantly shorter femoral neck (4.5 +/- 0.5 cm) than patients with subcapital fractures or osteoarthritis (5.4 +/- 0.4 cm). It may be that this difference in femoral neck length is related to the site at which a proximal femoral fracture occurs.