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.

The longevity of cemented femoral components has been shown to be related to the cement used. The reason for this difference between the available commercial preparations is unclear. One mode of failure of the stem is thought to be cracking within the cement mantle. This may be secondary to residual stress resulting from shrinkage of the cement on curing. It was hypothesised that there was a difference in shrinkage on curing between the different polymethylmethacrylate cements used commonly in hip arthroplasty.

Under standardised conditions, a fixed volume of Palacos-R, Palacos-LV, Simplex, CMW1 Radio-opaque, CMW2 and CMW Endurance was mixed under vacuum and allowed to cure in a measuring cylinder of fixed volume. The cylinder was then split open 24 hours later and the block of cement removed. The final volume of cement was then determined by measuring the volume it occupied in a container filled with water using Archimedes principle.

Our results indicate that, under standardised conditions, the degree of shrinkage for each commercial preparation was Palacos-R 6.9%, CMW1 5.2%, CMW2 5.4%, CMW Endurance 5.3%, Simplex 5.8% and Palacos-LV 7.2%.

There is a difference in the amount of shrinkage on curing between the different types of bone cements in use commercially and this may account for their differences in long term outcome.

Purpose: To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Methods and results: We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, four patients died of unrelated causes and two patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the AOFAS hindfoot score and three independent observers reviewing radiographs.

Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion: Despite a high rate of ankle and subtalar non-union most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and sub-talar joint arthritis, patients should be warned of the potential for non-union and high complication rates.

Implantation of allograft bone continues to be an integral part of revision hip surgery. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing bone in order to reduce that risk. One part of that processing can be carried out immediately prior to implantation using pulsed irrigation.

We report the incidence of deep bacterial infection in a series of 138 patients undergoing 144 revision hip arthroplasty procedures who had undergone allograft bone implantation. The allograft bone used was fresh-frozen non-irradiated. Allograft femoral heads were milled following removal of any residual soft tissue and sclerotic subchondral bone. The bone chips were then placed in a standard metal sieve and irrigated with Normal Saline (pre-warmed to 60 degrees Centigrade) delivered as pulsed lavage at 7 bar pressure. No antibiotics were used in the irrigation solution. The bone chips were washed until all visible blood and marrow products had been removed.

The deep infection rate at a minimum one year follow-up was 0.6%. This method of secondary processing appears to be consistent with a very low risk of allograft related bacterial infection.

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.

Purpose To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Method We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, two patients died of unrelated causes and four patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post-traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the American Orthopaedic Foot and Ankle (AOFAS) hindfoot score and with three independent observers reviewing radiographs.

Results Radiologically 17 ankles fused, three probably fused whilst 16 (33%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Postoperatively the mean AOFAS score was 51, 25 patients were satisfied (of these 50% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion Despite a high rate of ankle and subtalar non-union, most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and subtalar joint arthritis, patients should be warned of the potential for non-union and high complication rates.

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.

The early results of revision osteoarticular allografts in weight-bearing joints are reported. Sixteen consecutive patients underwent surgery over a six-year period between 1982 and 1988. At the time of review eight patients (50%) had surviving second allografts with an average follow-up time of 48 months (range 12 to 87). Five patients were graded excellent according to the Mankin scale, one good and two fair. Eight patients (50%) required further surgery, but only two patients came to amputation.