We undertook a comparative audit of 171 consecutive Hip and Knee Arthroplasties performed by an overseas team at an Independent Hospital (Group 1) between August 2005 and December 2005 and compared them to a corresponding number performed by all grades of surgeons at the local NHS Trust (Group 2). We examined patient selection criteria such as BMI and ASA grade and compared the early radiological outcome, complication rate, length of hospital stay and the patient satisfaction rate between the two groups.

We found that patients in Group 1 had a lower average BMI (27.13) and a better ASA grade (95% grade 1 and 2) as compared to Group 2 (BMI - 29.69 and 80% ASA Grade 1 and 2). The average hospital stay was 6.1 days in Group 1 and 8 days in Group 2.

Only 74% of the patients in Group 1 were completely satisfied with their treatment outcome as compared to 91% in Group 2. (Trent Arthroplasty Questionnaire)

There were 7 early dislocations (9.1%) in Group 1 (76 THRs), two requiring revision, as compared to one in Group 2 (1.3%, 84 THRs). Three other patients from Group 1 (TKRs) required a revision procedure within the first year.

There was an increased incidence of adverse features (mal-alignment and mal-positioning of components) on the post operative X rays of patients in Group 1 as compared to Group 2 leading to adverse clinical events. 11 patients (95TKRs) showed substantial femoral notching in Group 1 as compared to 3 in Group 2.

This study shows that patients selected for surgery by the overseas team were the fitter of the two groups, but had a significantly higher complication rate and a much lower satisfaction rate. The study underlines the potential risks of commissioning work to overseas teams in order to reduce waiting times.

120 patients undergoing primary TKR/THR were randomised to receive ferrous sulphate (FS) or placebo (P) for three weeks following their arthroplasty. Haemoglobin levels and absolute reticulocyte counts were measured at days 1 and 5, and weeks 3 and 6. Ninety-nine patients FS (50), P (49) completed the study. The two groups differed only in treatment administered. Haemoglobin recovery was similar at day 5 and by week 3, haemoglobin levels recovered to 85% of their pre-operative levels, irrespective of treatment group. A small but greater recovery in haemoglobin level was identified at 6 weeks in the FS group for females (6% Vs 3%) and males (5% Vs 1.5%). The clinical significance of this is questionable and may be outweighed by the high incidence of reported side effects of oral iron, and the economic costs of the medication. Administration of iron supplements following elective TKR or THR does not appear to be a worthwhile practice.

We report the results of the Charnley Elite Plus femoral stem (Ortron 90; Depuy, Leeds, United Kingdom) in multiple surgeon’s hands at a minimum of three years post implantation.

The long term results of the Charnley femoral stem have been widely documented . There have been numerous changes to the design and instrumentation of this original stem since its introduction in 1962, and the Charnley Elite Plus represents the fifth generation of this highly successful implant.

Between March 1994 and March 1998, 244 patients underwent 268 primary hip arthroplasty procedures using this particular stem. Patients were reviewed at a mean of 4.5 years (3.0 – 6.8 years) following their arthroplasty using the Oxford Hip Score and plain radiographs.

There were five revision procedures for aseptic loosening (5/268; 1.9%). Radiological assessment revealed gross radiological failure in a further 12 femoral stems (12/208; 5.8%). There was evidence of focal osteolysis with an apparently stable implant in 36 hips (17.3%).

In the best case scenario, using revision for aseptic loosening as the endpoint, the survivorship for this period is 98.1%. If radiographic failures are incorporated into this endpoint, survivorship is 93.1%. Of potential concern however, is the number of adverse features noted on the radiographs, with only 76.9% being categorised as ‘normal.’

The Charnley Elite Plus stem has undergone some fundamental design changes from the original Charnley stem and therefore clinical success should not be automatically assumed. In such circumstances we recommend regular clinical and radiographic follow-up of patients who have have undergone total hip arthroplasty with this particular femoral stem.

Purpose: To evaluate the outcome of the Elite Plus femoral stem in multiple surgeons’ hands at a minimum of three years post implantation, in accordance with guidelines published by the National Institute for Clinical Excellence.

Methods: Between March 1994 and March 1998, 199 patients underwent 224 primary total hip replacement procedures using the Elite Plus femoral stem at the Glenfield Hospital, Leicester. Seven different Consultant Orthopaedic Surgeons implanted these stems during this period. Patients were reviewed at a mean of 4.75 years following surgery using the Oxford Hip Score and plain radiographs. The mean age at operation was 62.3 years. Between March 1994 and March 2001, 12 patients underwent re-operation for all reasons, and 13 died. Oxford Hip Scores were returned from 159 patients (177 stems; 88.9%) and an AP and lateral radiograph obtained on 145 patients (162 stems; 81.4%)

Results: There were five known revision procedures for aseptic loosening (5/224; 2.2%). The mean Oxford Hip Score was 24 (range 10–54). Radiological assessment revealed gross failure in a further 11 femoral stems (11/162; 6.8%), and adverse radiological features in a further 28 stems (28/162; 17.3%)

Discussion: In the ‘best case’ scenario, a combined revision and radiographic failure rate of 9% is higher than expected. Antero-posterior positioning of the stem, resulting in bony cortical contact, appeared to produce a characteristic progressive osteolytic lesion which resulted in early implant failure. Additional possible modes of failure are discussed.

The management of periprosthetic femoral fractures around a total hip replacement can often be difficult and challenging; especially as they often occur in elderly patients with marked osteolysis and thin cortices.Various non-surgical and surgical treatment modalities have been described.

We reviewed 24 patients with type B fractures (Vancouver classification) managed with a cementless, tapered, fluted and distally fixed stem utilising a trans-femoral approach.There were 15 female and 9 male patients.The average age was 74 years.The average interval between the index operation and surgery was 10.8 years. The majority of the fractures occurred following trivial trauma. The average duration of the surgical procedure when both the cup and the stem were revised was 3 hours 14 minutes and 2 hours 14 minutes when only the stem was revised. The average operative blood loss was 1700 mls and 940 mls respectively. There were five dislocations. Three were managed conservatively without further problems. Two patients were treated surgically. There were two cases of nonunion one of which was secondary to infecton.

The average Harris hip score at follow-up was 69.The majority of the fractures united (91%). The average radiological subsidence was 5 mm post-operatively. Subsidence occurred within the first 6 months prior to fracture union with no further subsidence thereafter. Subsidence was notably absent in those patients in whom the fracture failed to unite. The majority of the patients showed a relatively good health status at follow-up.

This technique for the management of this difficult problem offers the advantage of providing a relatively short operative time with reduced patient morbidity.It allows early mobilization and the majority of the fractures unite uneventfully.

The biggest uncertainty surrounding this type of stem is the long-term survivorship in the younger patient.