Introduction: The use of H A coated implants for Total Hip Replacement is now well established. We are entering an era where some of these implants are requiring revision. This presentation reviews our experience of revising H A coated THR, considers the failure pattern and attempts to produce a rational method of treatment.

Methods: This is a retrospective study of all HAC coated implants revised by a single surgeon (senior author) covering last five years. It includes 20patients (21 Hips) eleven male and 9 female. The mean age at revision was 62 years (26–82 yrs). The mode of failure suggested three failure patterns hence we have divided them in three groups.

Results:

Early Failure 0– 2 years : Six hips

Early Failure: The cause for early revision in most cases was technical problems with the primary procedure with improper seating of liner, cup or femoral stem. Correcting the primary problem led to satisfactory results in this group.

Medium term failure: Medium term failure were found to be due to either liner failure or infection. Replacing the liner and two staged revision for infection gave good results.

Long term failure: All cases in this group were due to plastic failure, which led to aseptic loosening of acetabular shell in five cases and aseptic loosening of cup and femoral stem in further two cases.

Only loose components were replaced.

Analysing this series we conclude that in absence of infection only loose components should be replaced. Well held components should be left alone and only the failing component need to be revised.

Introduction: We studied the possible causes of intraoperative metaphyseal fractures in elderly patients with displaced intracapsular fracture neck of femur treated with an HAC coated bipolar hemiarthroplasty and their effect on patient morbidity.

Methods: 326 patients with 337 displaced intracapsular fractures admitted from November, 2001, to November, 2005 were included. They underwent Furlong bipolar hemiarthroplasty marketed by Joint Replacement Instrumentation Ltd (JRI). The operations were performed by employing a similar technique and anterolateral approach. Postoperative management was same.

Results: Thirty five (10.25%) patients sustained an intraoperative metaphyseal fracture. We found a strong correlation between the incidences of metaphyseal fracture and stem size. Size 9 stem was used in 80 patients without any fracture. Stem size 10 was used in 159 patients and was associated with metaphyseal fractures in 14 patients (8.80%); size 12 stem was used in 98 patients with 21 metaphyseal fractures (21.42%). Vancouver type AL fractures were 26 and 9 type AG. The fracture was found to be unstable and fixation was undertaken in 7 patients. The mean hospital stay for the patients without metaphyseal fracture was 24 days (range 2–83) in comparison to 30 days (range 17–96) for patients with fractures.

Thirty one patients presented from 3–18 months after operation with hip related problems, 17 had thigh pain, 10 periprosthetic fractures but 8 of these 27 had history of intra-operative metaphyseal fractures. Four patients had revision surgery, one each for acetabular erosion and sinking of prosthesis due to old metaphyseal fracture, two had Girdlestone arthroplasty due to deep wound infection.

Conclusion: We conclude that a size 12 stem was associated with high complications rate because there is a big jump for the elderly patients from size 10 to 12 due to the non-availability of size 11 stem in this system. We observed the effect on patient morbidity due to metaphyseal fractures.

Introduction:- We reviewed 69 patients with subcapital fracture neck of femur treated with two hole plate DHS and parallel de-rotation screw into the cranial part of the femoral head between January 2000 to January 2005.

Methods:- Patients were selected for fixation by having Garden 1 to 4 fractures, being younger, more active and mobile. Reduction was classified as “good” when residual angulation in the lateral projection was less than 15 degrees, no varus angulation and good alignment in the calcar area. Screw position was considered “good” when there was less than 10 degrees deviation in the direction of screws, screw threads not bridging the fracture site, screw tips less than 5mm from subchondral bone and no signs of intra-articular penetration. The fracture was considered healed when bridging of trabecular bone was present. Patients were reviewed until they were pain free at rest or on walking and had radiological healing of fracture.

Results:- 13 had Garden 3 & 4, 46 had Garden 1 & 2 and 10 had impacted fractures. Sixty eight patients had operation within 24 hours in the next available trauma list. Average age at operation was 70 years (range 21– 89) and hospitals stay 13 days (range 2–52). Good reduction was achieved in 61 patients, 54 of these had good screw position, 8 patients (11%) had combination of poor reduction and poor screw position; five of them had loss of fixation within 6 to 12 weeks postoperatively, one each had segmental collapse and avascular necrosis between 12 to 24 months of operation.

Conclusion:- Their was no re-displacement, non-union, avascular necrosis or segmental collapse when fractures were well reduced and had good screw position. Two hole plate DHS and a parallel de-rotation screw has high rate of fracture union. We recommend its use for treatment of subcapital femoral neck fractures.

The purpose of this study was to review the midterm results of HAC coated bipolar hemiarthroplasty in patients with displaced intracapsular fracture neck of femur in elderly patients.

There were 264 patients with 274 fractures from November, 2001, to June, 2004. The operations were performed by employing a similar technique and anterolateral approach. Postoperative treatment was same. The mobility was assessed by ambulation. Pain was evaluated using a visual analogue scale and clinical evaluations were performed using the Harris Hip Scoring System.

The mean age of 142 survived patients reviewed in the study was 77.5 years (range 61-89 years) at the time of operation and mean follow-up was 25 months (range 18-48 months). Hundred and twenty six patients had no or mild occasional pain but no restriction of activity. Ninety of the ninety eight able to walk independently or with one stick before fracture were doing the same. The surviving implants were radiographically stable and demonstrated evidence of osseointegration and no acetabular wear. Harris hip score averaged 84 points. Fourteen patients (10%) scored 90-100, 80 patients (56%) scored 80-89, 42 patients (30%) scored 70-79, and 6 patients (4%) scored less than 70.

We conclude that patients who score grade 1-3 of American Society of Anaesthesiologist and are mobile preoperatively outside their own home either independently or with one stick are better treated with HAC coated bipolar hemiarthroplasty with extra benefit of easy and quick conversion to total hip replacement if required in future.

Aim: To evaluate the medium term results of revision hip replacements using the ‘Furlong’(© JRI, London) HAC covered total hip replacement system.

Methods: The first one hundred revision hip replacements were identified from the arthroplasty register of the senior author. The notes and x-rays at presentation were retrospectively analysed to ascertain the clinical and radiological state pre-operatively. The surgical findings were also noted. The final clinical and radiological states were obtained from the latest outpatient appointment. Modified Harris Hip Score was used to discern the clinical state. SPSS © vol 11.0 was used for statistical analysis.

Results: There were one hundred revision hip replacements performed in 97 patients between 1991 and 2000 by the senior author. There were 72 cemented and 18 uncemented prosthesis revised. 9 of the revisions were for infection. 79 were revised for aseptic loosening of one or both of the components. There were 4 recurrent dislocators and one revision was carried out for a peri-prosthetic fracture.

The median to follow up was 3 years (mean 3.8, range 1–8).The changes in the clinical state of the patient at the last follow up are shown in the table: At the time of the latest follow-up 74 of the cups and 69 of the stems showed definite radiological signs of osseointegration.

Discussion: Our results show that clinical results of revision surgery using this system give good results in the short to medium term. Radiological results are less easy to interpret as osseointegration can take a long time to become visible on x-rays. The need for longer term follow-up is highlighted by the results.

Unstable fractures of the forearm in children present problems in management and in the indications for operative treatment. In children, unlike adults, the fractures nearly always unite, and up to 10° of angulation is usually considered to be acceptable. If surgical intervention is required the usual practice in the UK is to plate both bones as in an adult. We studied, retrospectively, 32 unstable fractures of the forearm in children treated by compression plating. Group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only. The mean age was 11 years in both groups and 23 (71%) of the fractures were in the midshaft. In group B an acceptable position of the radius was regarded as less than 10° of angulation in both anteroposterior (AP) and lateral planes, and with the bone ends hitched. This was achieved by closed means in all except two cases, which were therefore included in group A.

Union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B. After a mean interval of at least 12 months, 14 children in group A and nine in group B had their fixation devices removed.

We analysed the results after the initial operation in all 32 children. The 23 who had the plate removed were assessed at final review. The results were graded on the ability to undertake physical activities and an objective assessment of loss of rotation of the forearm.

In group A, complications were noted in eight patients (40%) after fixation and in six (42%) in relation to removal of the radial plate. No complications occurred in group B.

The final range of movement and radiological appearance were compared in the two groups. There was a greater loss of pronation than supination in both. There was, however, no limitation of function in any patient and no difference in the degree of rotational loss between the two groups. The mean radiological angulation in both was less than 10° in both AP and lateral views, which was consistent with satisfactory function.

The final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%).

If reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm, operation on the radius can be avoided.