In 2002 the UK government in its attempt to reduce long total joint arthroplasty waiting lists, arranged for local councils via NHS trusts to send patients abroad for their surgery. In theory it was a win-win situation where pressures upon surgeons were reduced, trusts could reach government targets and of course, patients got their operation with a bonus holiday! Unfortunately, it was not until patients had returned from their surgery that problems with this method of waiting list reduction were realised. The majority of patients were discharged after only one check up and often had very little in the way of post operative physiotherapy. A few presented to our clinic with more serious complaints with two cases eventually requiring revision surgery.

We undertook a case-control study looking at an age and sex matched group of patients who underwent total knee arthroplasty, Group A (Belgium) and Group B (Local Institution) during the same time period from November 2003 to November 2004. We compared their Oxford knee score (OKS), Knee society score (KSS) and SF12 physical and mental component scores.

Introduction: Impaction allografting is a technique that is used at revision where the bone stock in the femur is poor. Femoral heads are ground to create morsellised bone, which is impacted down the femur prior to the cementing a new stem into the canal. The results of this technique are variable and there is a high incidence of stem migration. This variation in results may be due to the degree of bone loss or the techniques used to impact the graft. The aim of this study was to quantify the forces currently used in revision hip surgery with impaction allografting.

Methods: To enable these measurements the Exeter slap hammer (Stryker Howmedica) was altered to include a load washer. The load washer had a special cable welded to it so that sterilisation could still be conducted in an autoclave. During surgery the end of the load washer cable is passed to the operator, who is able to connect it to a laptop computer. A specially written Labview program is then used to store the data and determine the impaction forces. The load washer is mounted within the hammer at the point of impact between the sliding mass and the hammer, consequently it is reading the force transmitted to the hammer, not that transmitted to the graft chips. Calibration was performed in an in vitro experiment with a second load washer, which found that the force in the hammer is three times that in the impactor. The force is so much less because it is taken up in the hammer’s inertia.

Conclusions: The impaction forces have been measured during eight operations performed by three different surgeons. The study shows variability between surgeons, and variability between patients operated on by the same surgeon. These readings show that the forces travelling through the impactor range between three to eleven time body weight.

Aims: The aim of this study was to compare the results of Micro Endoscopic Discectomy (MED) toMicro Surgical Discectomy (MSD). Methods: 12 Patients were reviewed by an independent observer. This included the þrst 6 patients who underwent MED and 6 patients who underwent MSD selected randomly. There was no signiþcant difference between the two groups concerning age and sex distribution, occupation, preoper-ative time of work and clinical symptomatology. The disc herniations were located at L4-5 in 6 patients and L5-S1 in 6 patients. Patients were followed up for an average of 9 months (Range 2–22 months). They were assessed using the following questionnaires Oswestry low back pain and disability, Modiþed Gre-enough and Fraser and Mc Nab. Results: Both groups faired equally according to Mc Nab. The MED group appeared to require less postoperative analgesia especially opioid based preparations and were discharged earlier. The only complication was one patient in the MED requiring conversion to MSD. Conclusion: Our results indicate that MED is at least as effective as MSD, although it initially takes longer to perform due to the learning curve. However, the decrease in postoperative analgesia requirements and earlier discharge is beneþcial. In addition, we feel it has advantages over the percutaneous posterolateral discectomy for nerve root compression, which cannot treat sequestrated discs, or patients with disc herniations associated with recess stenosis.

Introduction: The conversion of the fused hip to a total hip replacement poses a challenging reconstructive problem. The technical pitfalls depend on the aetiology of the arthrodesis, the surgical technique used and the available bone stock. Indications include painful pseudo arthrosis, disabling back or ipsilateral knee pain and malposition of the arthrodesed hip. There are often difficulties restoring appropriate biomechanics and providing a functionally useful outcome. We present a short series where a custom CAD/CAM femoral prosthesis was used to accommodate the anatomical problems caused by previous spontaneous and operative arthrodesis.

Patients and Method: 5 patients (4 female, 1 male) with primary diagnoses of septic arthritis, TB, trauma and DDH were reviewed. The average age at the time of conversion was 43.6 years (Range 20–62 years). The patients were reviewed with a mean follow up of 82 months (Range 24–110 months). All the patients were evaluated by an independent observer radiologically and clinically using Harris, WOMAC and Oxford hip scores.

Results: The patients improved from preoperative HHS 55 (Range 39–73), Oxford 40 (Range 37–46) and WOMAC 80 (Range 65–92) to postoperative HHS 73 (Range 44–94), Oxford 26 (Range 17–42) and WOMAC 45 (Range 24–79). These results compare poorly to a large series of age and sex matched cases undergoing primary and revision hip arthroplasty. Nevertheless, 4 patients were extremely satisfied with the results of their operation. 1 patient showed no improvement in his scores although he reports that his spinal symptoms are better. His operation was complicated by non-union of the greater trochanter.

Conclusion: Most series report poor results after the conversion of arthrodeses to total hip replacements. The commonest problems include instability, sepsis, fractures, limited mobility of the hip replacement and poor function. Careful planning is required to accommodate the atypical anatomy. The use of CAD/CAM femoral stems in the conversion of the arthrodesed hip has allowed preservation of valuable bone stock in anatomically abnormal femora whilst optimising biomechanics and improving function.

Introduction: Developmental dysplasia of the hip (DDH) is a common cause of secondary osteoarthritis of the hip. The severity of the hip dysplasia varies considerably leading to a broad spectrum of reconstructive challenges. The custom CAD/CAM femoral stems offer a useful solution to fit and correct the abnormalities in the anatomy of the proximal femur.

Materials and Methods: The purpose of the study was to review at the functional and radiological outcome of uncemented CAD/CAM stems where the primary diagnosis is DDH. Uncemented sockets were used in all cases. Pre-operative planning consisted of a CT scan to assess the available acetabular coverage, estimate the degree of femoral anteversion and precisely evaluate the limb-length inequality. The hips were classified according to Crowe and Hartofilakidis. Patients with less than two-year follow up were excluded. The outcome was determined radiologically and using the Harris, Oxford and WOMAC scoring systems.

Results: Ninety-nine cases were identified and included in the study. The mean age of the group was 43.8 (range 26–79) with a female to male ratio was 4 to 1. The average follow up time was 5 years (range 24–118). The majority of the patients had excellent outcomes with a significant improvement in their clinical scores. The pre-operative scores were Harris Hip score 43.8 (range 9–81), Oxford 41.6 (range 19–59) and WOMAC 77.3 (range 10–120). Post operatively the scores have improved to Harris Hip Score 84.2 (range 38–99), Oxford 20.3 (range 12–48) and WOMAC 37.1 (range 24–92).

Conclusion: Total hip replacement for the sequelae of hip dysplasia is associated with high failure and complication rates. CAD/CAM stems afford a great deal of flexibility for the management of a broad spectrum of anatomical problems in these cases and provide a very useful alternative to modular prostheses. We present excellent medium term results.

Introduction: Patients with developmental dysplasia of the hip with secondary osteoarthritis are often found to have severe anatomical deformities of the hip. Total hip replacement in such patients is a complex undertaking associated with complication and failure rates. Subtrochanteric derotational osteotomy with customized uncemented total hip arthroplasty has been described to combat the problems of severe femoral anteversion. We present the medium term follow up of 12 patients where such a procedure was undertaken.

Materials and Methods: 11 female and 3 male patients with an average age of 49 (range, 32–79 years) were reviewed by an independent observer. The mean follow up was 50 months (range, 24–93 months). Patients were classified on AP radiographs according to Crowe and Hartofilakidis. All have femoral neck anteversions of greater than 45° on CT scans. The patients were followed up radiographically and clinically using the WOMAC, Oxford and Harris hip scores.

Results: 1 patient died due to unrelated causes. The average Harris hip score improved from 44 (range, 38–57) preoperatively to 88 (range, 67–94). The average WOMAC score improved from 83 (range, 45–112) pre-operatively to 36 (range, 25–72). The average Oxford score improved from 44 (range, 38–57) preoperatively to 19 (range, 14–34). Radiologically, the prosthesis appears to have osseointegrated with union of the osteotomy site in all cases and there is no evidence of implant migration or osteolysis.

Conclusion: Custom total hip arthroplasty with subtrochanteric osteotomy provides a method whereby the hip centre can be restored to its normal level, proximal bone stock is preserved and a more normal proximal femoral morphology is created. We have undertaken this procedure routinely in patients with excessive femoral anter-version and report excellent medium term clinical and radiographic results.

Introduction: An increasing number of patients present for revision hip replacement with severe bone loss. The results of cemented revision in these cases are poor. This study was conducted to determine the medium term clinical and radiological outcome of 50 consecutive revision hip replacements performed using custom femoral stems.

Materials and Method: 50 consecutive hips (49 patients) performed by the senior author between 1992 and 1995 were identified. The indications for revision were aseptic loosening in 42 cases, infection in 7 cases (6 of which were revised using a two-stage technique), and dislocation in one case. The stems are manufactured on the basis of standardised measurement films using specially developed software. The design includes proximal macrogrooves with hydroxyapatite coating, an anterior flare, a lateral flare and a collar. The average follow up was 88.4 months (range 12–111 months). All patients were evaluated radiologically and using Harris, Oxford and WOMAC hip scores.

Results: The patients were assessed by an independent observer. All had severe bone loss according to AAOS and Paprosky classifications. 5 patients died due to causes unrelated to their hip replacement, 5 were lost to follow up or did not respond to questionnaires sent. The remaining patients had average preoperative scores of HHS 40.8 (range 8–87), Oxford 43.5 (range18–56) and WOMAC 82.5 (range 40–120) and had improved to HHS 74.4 (range 19–99), Oxford 25.5(range 12–51) and WOMAC 43.8 (range 13–89).

Conclusions: The use of customised revision stems allows the implant to be tailored to the patient’s bone stock and femoral anatomy. This technique avoids the massive inventory of implants and trials needed for highly modular revision systems, but nevertheless leads to excellent bone implant apposition and interface stability. The clinical results are excellent at medium term review, and the survivorship compares very favourably with other revision series.