NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively).

This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts.

Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%).

In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results.

Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision.

All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded.

43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change, or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group.

With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures.

This study assesses the incidence of noise in ceramic on ceramic (COC) bearings compared to metal on polyethylene (MOP) bearings. Noise after MOP implants has rarely been studied and they never been linked to squeaking.

We have developed a noise characterising hip questionnaire and sent it along with the Oxford Hip Score (OHS) to 1000 patients; 509 respondents, 282 COC and 227 MOP; median age 63.7 (range 45–92), median follow up 2.9 years (range 6–156 months).

47 (17%) of the COC patients reported noise compared to 19 (8%) of the MOP patients (P=0.048). 9 COC and 4 MOP patients reported their hip noise as squeaking. We found the incidence of squeaking in the COC hips to be 3.2% compared to 1.8% in the MOP hips. Overall, 27% patients with noise reported avoiding recreational activities because of it and patient's with noisy hips scored on average 4 points less in the OHS (COC: P=0.04 and MOP: P =0.007).

This is the first study to report squeaking from MOP hip replacements. We therefore believe the squeaking hip phenomenon is not exclusive to hard bearings. Surprisingly, only a small proportion of patients described nose from their as a ‘squeak’. Noisy hip implants may have social implications, and patients should be aware of this. We have shown a relationship between noise and a lower OHS. However, longer follow-up and further study is needed to link noise to a poorly functioning implant.

While an increasing amount of arthroplasty articles report comorbidity measures, none have been validated for outcomes. In this study, we compared commonly used International Classification of Diseases-based comorbidity measures with re-operation rates after total hip replacement (THR). Scores used included the Charlson, the Royal College of Surgeons Charlson, and the Elixhauser comorbidity score. We identified a nationwide cohort of 134 423 THRs from the Swedish Hip Arthroplasty Register. Re-operations were registered post-operatively for up to 12 years. The hazard ratio was estimated by Cox’s proportional hazards regression, and we used C-statistics to assess each measure’s ability to predict re-operation. Confounding variables were age, gender, type of implant fixation, hospital category, hospital implant volume and year of surgery.

In the first two years only the Elixhauser score showed any significant relationship with increased risk of re-operation, with increased scores for both one to two and three or more comorbidities. However, the predictive C-statistic in this period for the Elixhauser score was poor (0.52). None of the measures proved to be of any value between two and 12 years. They might be of value in large cohort or registry studies, but not for the individual patient.

Cite this article: Bone Joint J 2013;95-B:1184–91.

The link between squeaking and ceramic on ceramic (CoC) bearings has been widely reported in orthopaedic literature and is described as a hard bearing phenomenon. We aim to look at the incidence of noise in CoC bearings compared to Metal on Polyethylene (MoP) bearing, which have yet to be linked to squeaking.

We developed a noise characterizing hip questionnaire and sent that along with the Oxford Hip Score (OHS) to 1000 patients; 3:2 ratio of CoC to MoP. 282 CoC patients and 227 MoP patients returned the questions: 509 patients in total. Our patient database provided details on femoral head size and the acetabular inclination angle, for each respondent

47 (17%) of the CoC hip patients reported noise compared to 19 (8%) of the MoP hip patients (P=0.054). 9 CoC patients and 4 MoP patients reported squeaking, while clicking was the most frequent answer in both groups. 27% patients with noise reported avoiding recreational activities because of it. Patient's with noisy hips scored on average, 5 points worse in the OHS (CoC: P = 0.04 and MoP: P = 0.007) and were on average 5 years younger (CoC: P<0.001 and MoP: P=0.007). No correlation was found between noisy hips and femoral head size or inclination angle.

The squeaking hip phenomenon is not exclusive to hard bearing THA. Noise from patient's hips may have social implications and this should be highlighted when consenting a patient for either of these hip procedures. In both implants, we showed there to be a correlation between noise production and a lower OHS. However, longer follow up studies are needed to link noise to a poorly functioning implant

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty.

We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis.

A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2^nd postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort.

In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.

The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA).

A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients.

16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements.

No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life.

Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group.

The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause.

The Trident acetabular system is the second most common cementless cup implanted in the UK. Recent studies have shown that malseating of the liner can be as high as 16.4%. We felt this was very high and were prompted to review our series and early clinical outcomes.

We reviewed 118 hips in 110 patients, implanted between from 2005-2007. We reviewed initial post operative X-rays using the technique described by Howcroft to identify malseating. The posterior approach was used in all cases. All cups were Trident PSL and all 85 Patients had OA, 10 RA, 8 AVN, 5 DDH, 3 OA post trauma, 2 Perthes, 2 Psoriatic Arthritis, 3 other. We only identified 3 malseated cups in 118 hips. 2 were in patients with OA secondary to trauma and 1 in primary OA. The rate of malseating for trainees operating was 5 % and only 1% when consultants were operating. There were no adverse events in these patients. No-one required revision. Oxford Hip Score (OHS) improved from 47 pre-op to 20 post op. This was compared to 47 and 22 in the correctly seated group (115 cases). Surprisingly the subgroup with the poorest OHS at 1 year had surgery for DDH, with a mean OHS of 31. The reasons for this are unclear.

Contrary to other studies our malseating rate is very low. We do not feel that malseating is a problem with Trident if adequate exposure is obtained. In those patients with sclerotic bone, we suggest over reaming the rim of the acetabulum by 1mm to avoid excess deformation of the shell which may lead to difficulty with seating the liner. We suggest trainees are supervised closely when using Trident.

Exeter Trauma Stem (ETS) is one of the most common implants used for treating displaced intracapsular hip fractures in the UK. We previously performed a radiographic audit of these implants which showed good placement was difficult. This was in particular relation to leg length discrepancy (LLD). This study reviewed the clinical outcomes of these patients, in particular looking at the relation of leg length discrepancy to outcome.

We performed a clinical review of patients at 3 months and 1 year post ETS for hip fracture. Oxford hip score (OHS), Trendelenberg test, Visual Analogue Score (VAS) and walking aids required were recorded. Leg length discrepancy was determined radiographically on initial post op X-ray. This was recorded as Even (+/− 5mm), 6-10mm Long and >10mm long.

Seventy-two patients were reviewed at 3 months and 21 at 1 year. Mean VAS was 1.6. At 3 months 66% were Trendelenberg positive. Of those Trendelenberg positive at 3 months only 42% remained positive at 1 year. Mean OHS at 3months and 1 year was 30.8 and 32.1 respectively. On radiographic review 38 implants were Even, 24 were 6-10mm Long and 10 implants were >10mm Long. There was no correlation between leg length discrepancy and either VAS or Trendelenberg test. 45 patients ambulated independently pre-op. Of these only 8 ambulated independently post-op, 18 used a stick and 11 a Zimmer frame.

There was no correlation between post operative leg length discrepancy and either Visual Analogue Score, OHS or Trendelenberg test. Mean pain score was very low. There was however almost 10% of patients with a VAS greater than 6. 80% of patients dropped one ambulatory level post-op, this is consistent with previous studies. The ETS provides good pain relief with a low complication rate in the vast majority of patients.

Post-operative check radiographs following Total Hip Replacements (THR) are routine practice in most orthopaedic units. In our unit an Anteroposterior and Turned Lateral View (TLV) radiograph was used routinely in this assessment, but the TLV method has anecdotally been reported as painful by patients. We undertook a study to evaluate patients' experiences of pain using this technique and to consider if a change to a Horizontal Beam Lateral View (HBLV) radiograph method would result in a reduction in pain.

The study was conducted in two phases. Patients who underwent a primary THR and subsequent post-operative TLV over 3months (n=46) were contacted by telephone and asked to grade their experience using a numerical and descriptive pain scale. After a change in practice to HBLV, the study was repeated (n=53) to identify any difference in pain. Ten radiographs were randomly selected from each group and assessed for radiation exposure and quality by two independent assessors.

87.0% of patients who underwent the TLV radiograph described the post-operative radiograph as painful, with a mean pain score of 7.44+1.5. After a change in practice to the HBLV radiograph, only 28.4% of patients experienced any pain, with a significantly lower mean pain score of 1.00+1.89 (p< 0.001). There was a significant increase in radiation dose in the HBLV vs. TLV method (62.4mAs vs. 25.8mAs, p< 0.001). HBLV X-ray quality was only slightly inferior to TLV when evaluating stem alignment and cement mantle quality.

There was a dramatic reduction in both number of patients experiencing pain and level of pain experienced when switching from TLV to HBLV radiographs; this is most likely due to reduced direct pressure on the wound post-operatively. X-ray quality was not compromised, and whilst there was increased radiation exposure, the benefits in patient experience were felt to outweigh this. We recommend the HBLV radiograph method when performing a lateral post-operative check x-ray following THR.

Introduction: There has been a proliferation of newer fluted tapered grit-blasted titanium stems in hip revision arthroplasty. However, only a limited number of clinical series have so far been reported in the literature. Moreover, all reports have only a short-term clinical and radiographical follow-up (< 5 years). Medium-term and long-term follow-up studies are lacking. Therefore, the aim of this study was to review a series of a cementless modular tapered revision femoral component (MP Link hip reconstruction prosthesis) with a minimum 5 year follow-up.

Patients and Methods: This study includes 90 consecutive cases (87 patients) with the MP stem. We documented the Harris hip score (HHS) and the Visual analogue scale (VAS) was used to assess pain at rest and movement. Survivorship was calculated using Kaplan-Meier survival analysis. The 95% confidence intervals (CI) for the cumulative 5 year survival were calculated. Radiographs made immediately after the index operation were compared with those at follow-up examination in order to classify the restoration of femoral bone and vertical migration of the implant.

Results: Of the original 90 cases, 24 (27%) died prior to clinical and radiographical review, 2 (2%) had a stem revision and 1 (1%) was lost to follow-up. Patients who died and were lost to follow-up were included in the survival analysis. For those patients, all data concerning complications and revisions were extracted from journal files and the Swedish Hip Register which collects all information on reoperations after hip revision surgery.

The median follow-up time was 6 (5–11) years. The median VAS for pain for the affected hip was 0 (0–5) at rest and 0 (0–9) at movement. The median HHS at follow-up was 78 (16–100) points.

17 (19%) patients dislocated their hips during follow-up. A prosthesis head size of 22 mm was present in 6/17 (35%) patients with dislocation and in 11/73 (15%) patients without dislocation (P = 0.055).

The cumulative 5 year survival rate was 98% (95% CI: 94–100%) with stem removal and 90% (95% CI: 85–96%) with any reoperation as the endpoint.

At follow-up, we noted subjectively that 17% of the cases had evidence of proximal bone restoration, whereas 44% had constant defects. In 39% the quality of the proximal bone appeared to be declining. If present, this was mostly seen around the lesser trochanter. The median vertical stem migration was 2.7 (0–30) mm

Discussion: This is the first report with a clinical and radiographical medium-term follow-up of patients with a cementless modular tapered distally fixated hip revision stem. In our study, we found a discrepancy between a high implant survivorship and good pain relief on one hand and a high dislocation rate on the other hand.

Background: Resurfacing is becoming increasingly popular as an option for primary hip arthroplasty. However, there is minimal documentation of objective post-operative outcomes which support the perceived benefits of resurfacing over traditional stemmed THR. Most comparative studies have reported differences in X-ray findings, such as component alignment and femoral offset, which only allow speculation of their relative effects on patient function. Studies have also reported general clinical outcomes following resurfacing, and although resurfacing shows promising medium term results, these studies have been largely subjective and have lacked a direct same study comparison with standard THR.

Potential benefits of resurfacing include improved abductor muscle function, resulting from preservation of the femoral neck offset, and greater range of hip motion, resulting from the larger diameter bearings. Mont et al (2007) compared biomechanical outcomes during gait for individuals with unilateral resurfacing and standard arthroplasty and concluded that hip resurfacing yielded superior function, as defined by faster walking speeds. However, comprehensive data of 3-dimensional moments and hip kinematics was not presented and functional assessment was limited to gait analysis only.

Methods: Kinematic and kinetic outcomes were evaluated for 28 individuals (age 40–60) with unilateral resurfacing (Durom, Zimmer) or standard stemmed THR (ceramic-on-ceramic Trident, Stryker) at 3 and 12 months following surgery. Data was collected using an 8 camera Vicon 612 motion analysis system and two Kistler force plates while subjects completed level walking and stair ascent and descent activities using a 4-step stair case, instrumented with a force plate on the second step. A lower limb marker set was used with pointer trial calibration of anatomical landmarks. 3-dimensional hip moments, angles and temporospatial parameters were compared and preferred motion patterns analysed.

Results: Peak hip moments showed no statistically significant group difference during the ambulatory activities although slightly greater peak hip angles were achieved by those with standard THR. Stair negotiation highlighted greater differences in biomechanical outcomes between the groups than level gait analysis. Those with hip resurfacing exhibited less protective motion patterns and performed walking and stair negotiation at a faster pace.

Conclusions: The greater diameter bearings of the resurfacing prosthesis do not appear to yield a greater functional range of motion post-operatively. Preserving the femoral offset with a hip resurfacing does not appear to benefit abductor muscle function. Statistically, both arthroplasty types demonstrate equivalent functional outcomes.

Introduction: Proximal bone loss in patients undergoing femoral hip revision surgery is a challenging and complex problem, as it is often impossible to implant a proximally anchored prosthesis in such cases. Fluted tapered cementless prosthesis stems, such as the Link MP reconstruction prosthesis represent a distal fixation option, allowing axial and rotational control of the implant in the femoral diaphysis.

The manufacturer of the MP hip stem recommends a distal femoral implant/bone anchorage of at least 80 mm to gain implant stability. However, there are no in vivo studies showing that this fixation length is achieved in clinical practice and that this distance is needed for clinical satisfying results. Therefore, the aim of this study was to assess the distal femoral fixation length of the MP reconstruction prosthesis by using computer assisted tomography (CT).

Patients and Methods: To evaluate stem anchorage of the MP reconstruction stem, we performed CT-scans on 14 patients at a median follow-up of 12 months (IQR 12–25) after surgery. All CT-scans were separately analysed by 2 blinded radiologists. Clinical outcome was assessed by VAS for pain and Harris Hip Score (HHS) both at 12 (IQR 12–25) and 68 (IQR 61–73) months after surgery.

Results: We found the CT-scans of good quality and almost free from disturbing metal artefacts, which made it easy to interpret the images. Intraclass correlation between the measurements of the two blinded radiologists was 0.935 corresponding to an outstanding inter-rater reliability.

The median length of femoral stem/bone anchorage was 33 mm (IQR 10–60) which was too short according to the manufacturer’s guidelines. Still, all patients were fully weight-bearing and only 1/14 complaint about mild thigh pain. 7/14 patients did not experience any pain at rest or movement in the affected hip.

The patients reached median 85 (IQR 77–94) points in the HHS, corresponding to a good result. At 62 months follow-up, the patients described the same pain scores and the HHS had still a good result with 81 (IQR 62–92) points.

Discussion: We could show that it is possible to analyse the distal stem/bone anchorage of cementless femoral implants by using CT. Moreover, we could show a clear discrepancy between the manufacturer’s guidelines and clinical practice concerning anchorage of the MP reconstruction prosthesis. It is difficult to achieve femoral stem/bone anchorage of at least 80 mm, which otherwise is not necessary to achieve stability and clinically satisfying results.

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology. In RA, inflammation and pain are initial symptoms followed by bone and cartilage destruction. Proinflammatory cytokines play a significant role in the initiation and progress of inflammation and tissue destruction. Sensory neuropeptide substance P (SP) participates not only in nociception but also in pro-inflammatory processes by enhancing vasodilatation and recruitment of inflammatory cells. Ubiquitin proteasome system (UPS) activates a transcription factor, NF-κB which regulates the synthesis of proinflammatory mediators like cytokines; however its role in regulating pro inflammatory sensory neuropeptides is unknown. A number of proteasome inhibitors have been shown to down regulate the activity of NF-κB and hence reduce inflammation. In the present study, the effect of proteasome inhibitor (MG 132) on the severity of arthritis and pain was observed along with the expression of SP-positive nerve fibres in the ankle joint in a chronic inflammatory model of rat adjuvant arthritis.

Histology and mechanical pain tests showed a significant reduction in inflammation and pain in ankle joint by daily administration of proteasome inhibitor MG132 at the dose of 1mg/kg body weight compared to untreated groups. Radiographic analysis of ankle joints indicated a reduction in soft tissue swelling and joint destruction in the treatment group. A marked reduction in the NF-κB activity was observed by EMSA. Furthermore, proteasome inhibition resulted in the normalization of up regulated neuronal response occurred during inflammation by significantly reducing the expression of SP-positive fibres in the ankle joint as demonstrated by immunohistochemistry.

Our data provide the evidence that proteasome inhibitor MG132 can reduce severity of arthritis and reverse inflammatory pain behaviour by influencing the peripheral sensory nervous system. The drugs targeting UPS can be developed for treatment of chronic inflammatory joint disorders.

Objectives. To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip.

Methods. In this prospective follow-up study 14 RA patients scheduled for ankle/hindfoot arthrodesis were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- versus post-operative conditions, Wilcoxon’s matched pairs test and Friedman ANOVA by rank test were used.

Results. At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up.

Conclusions. Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.

INTRODUCTION: Metal-on-metal alloarthroplasty of the hip is gaining popularity in order to avoid complications associated with polyethylene wear. On the other hand, metal-on-metal articulations release metal ions, the biological effects of which remain unclear. Genetic and immunological changes have been associated with increased metal ion levels in arthroplasty patients. We intended to study the outcome after metal-on-metal arthroplasty of the hip with a focus on the toxicologically and immunologically relevant metal ions chromium, cobalt, nickel, and manganese.

PATIENTS AND METHODS: A prospective, randomised study was designed where all patients received a cemented arthroplasty of the hip, either with a metal-on-metal bearing (Metasul ®; 28 patients) or with a metal-on-polyethylene bearing (Protasul ®, 26 patients). Only patients with primary osteoarthritis of the hip and without other metallic implants were included (mean age 65 years, range 45–74). Follow-up was performed after a minimum of two years. Clinical outcome was measured by the Harris hip score and the SF36, and radiographic analysis was undertaken by plain radiography. Metal ion concentrations in patient serum were analysed by high-resolution plasma mass spectrometry.

RESULTS: It was found that the clinical outcome was almost identical in both groups with respect to Harris hip score and SF36, and radiographic signs of osteolyses or loosening did not occur in any group. In the metal-on-metal group, chromium concentrations increased 4.1 fold and cobalt concentrations increased 7.6 fold when compared to preoperative values (p< 0.05; Wilcoxon Mann Whitney Test), whereas nickel and manganese concentrations did not change significantly. In the metal-on-polyethylene group, no significant increase in the concentration of any ion occurred.

DISCUSSION: In conclusion, metal-on-metal and metal-on-polyethylene arthroplasties of the hip provide equal clinical and radiographic outcomes in the medium term, but the concentrations of chromium and cobalt increase considerably after metal-on-metal arthroplasty. Importantly, the allergogenic and previously not assessed ions nickel and manganese show no significant changes in the medium term after any type of hip alloarthroplasty. To our knowledge, this is the first study that addresses manganese and nickel concentrations in a prospective, randomized setting, and our patients will be followed further with respect to possible immunological and genetic changes.

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group.

These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

We analysed the axis of movement in the normal elbow during flexion in vivo using radiostereometric analysis (RSA). The results show an intraindividual variation in the inclination of the axis ranging from 2.1° to 14.3° in the frontal and from 1.6° to 9.8° in the horizontal plane analysed at 30° increments. The inclination of the mean axis of rotation varied within a range of 12.7° in the frontal and 4.6° in the horizontal plane. In both planes, the mean axes were located close to a line joining the centres of the trochlea and capitellum. The intra- and interindividual variations of the axes of flexion of the elbow were greater than previously reported. These factors should be considered in the development of elbow prostheses.

We conducted an epidemiological study of osteosarcoma in Sweden from 1971 to 1984 to investigate whether the typical features of the disease had changed. Of 294 osteosarcoma patients reviewed, 249 had primary skeletal tumours, and for these the mean annual incidence was 2.1 per million, without any clear trend over time. The mean male/female ratio for the period was 1.6 again with no consistent pattern over time; nor was there any significant change in the distribution of tumours according to location. The only feature which showed a significant change over the 14-year period was the mean age of the patients, being at its lowest (19 years) in 1972 and at its highest (40 years) in 1981. Excluding the 22 patients with craniofacial tumours, the remaining 227 also showed a significant increase in mean age. Analysis of the annual age distribution disclosed an increasing fraction of patients older than those in the classical age peak between 10 and 29 years. A large number of trials have shown improved survival in osteosarcoma over the last 15 years, which has been attributed mainly to adjuvant chemotherapy. The change we have observed in age distribution should also be taken into account in the evaluation of the results of treatment; it may be that older patients have a better prognosis.