Aluminia ceramic on ceramic (COC) bearing surfaces have been used for 35 years in total hip arthroplasty (THA). Studies report 85% survival at a minimum follow-up of 18.5 years. Nonetheless, an audible noise is a finding associated with COC bearings with incidence rates of 2–10%. This study aims to determine the prevalence of noise and evaluate its effect on patients.

All patients who had a COC THA from August 2003 to December 2010 were contacted and asked to complete a standardised questionnaire. This asked about the presence and characteristics of a noise and if associated with activities, pain and whether this phenomenon should be mentioned preoperatively.

Four consultant surgeons performed 282 consecutive primary COC THAs in 258 patients. (Male=122, Female=136 mean age 68.5; age range 28–88). In all cases, the same brand of ceramic acetabular component and stems were implanted. 11.0% had a noise, of which 5.5% had a squeak. Pain was experienced in 38.7% of patients in hips that made a noise. There was no trauma and one dislocation in this group. In this study, 85% of noises occur during weight-bearing although no patients have reduced daily activities as a result of the noises. Of all the patients, 55.0% stated they would have preferred to have known about a noisy hip possibility before consenting but none would have refused consent.

Squeaking has not been a problem here despite the prevalence being higher than most in the literature. The authors recommend that squeaking should be discussed preoperatively. A checklist for Orthopaedic Trainees is being drafted to enable trainees to counsel patients appropriately, allowing patients a better opportunity to give informed consent.

Patients with osteoarthritis of the knee reviewed by the General practioners, are usually referred for further management to the orthopaedic surgeon. It was our observation that patients were usually referred with supine knee X-rays. This meant weight-bearing films were repeated at the clinic.

Methods: We sent out questionnaires to GPs inquiring whether they asked for X-rays of the knee prior to patient referral and whether they asked for weight bearing films. We also reviewed the policy in one National Hospital Service trust and one teaching hospital with regards to GPs asking for weight bearing films. The time patients spent waiting at the X-rays department was noted. Finally we inquired about the cost of a knee X-ray.

Results: A total number of 65 questionnaires were sent and the response was 44 i.e. 67%. 80% of the GPs asked for non weight bearing X-rays prior to referral. Only 5% asked for weight bearing films. The radiology departments of hospitals in one NHS trust and the teaching hospital did not accept weight bearing requests from GPs. The time taken for a patient to get an X ray in the department was at least 30 minutes and the cost of X rays of the knee was £51. With an average of two patients with osteoarthritis of the knee per clinic, the cumulative waiting time for repeated X-rays was 1 hr per clinic, 5 hrs per week and 240 hrs per year. With an average of two X rays per clinic the cumulative cost was £102 per clinic, £510 per week and £24480 per year.

Discussion: Non weight bearing X-rays of the knee do not add any value in making or confirming a diagnosis of osteoarthritis yet they are costly both in terms of time and money. Weight bearing films were repeated for patients with these X-rays. The cumulative cost in terms of time can be better used to review other patients and therefore reduce the waiting time before surgeons can see referrals. The other issue is the cumulative cost which can be put to better use in the trust. The time wasted by the patients who have repeated X-rays was not considered, but is also of importance.

Conclusion: Patients with osteoarthritis of the knee should have weight bearing films from the initial onset. This will save time for the patient and the surgeon and will save the hospital money.