Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell.

Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%).

At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis.

Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.

Excessive perioperative administration of intravenous fluid during lower limb arthroplasty may be associated with postoperative complications. There have only been five randomised trials that have evaluated the effects of intraoperative fluid on recovery time, none of which have looked at Orthopaedic patients. Intravenous fluid overload has been shown to decrease muscular oxygen tension, produce general oedema, delay tissue healing, compromise cardiorespiratory function and can cause coma.

This study assesses the current practice in the administration of fluid and sodium during and after lower limb arthroplasty in our hospital.

A series of 68 patients who have undergone elective THR (57) and TKR (11) were included in this prospective study. Current fluid management includes the use of Hartmans solution at a rate of 125mL per hour together with fluid boluses to maintain blood pressure and urine output. We looked at the weight of the patients before and after surgery and compared this with their pre and post operative serum sodium level.

Our findings were that patients gained an average of 1.84 Kilograms (Range −1.6 to +6.4) which was age dependent and there was a mean fall in Serum Sodium of 5.26 mmols/L (Range −15 to +2). Of note there was a mean fall in serum Haemoglobin of 3.69g/dL (Range −2.8 to −5.9) which may be due to blood loss perioperatively but haemodilution due to excessive fluid administration may also contribute.

We propose responding aggressively to low urine output and low blood pressure can cause detrimental effects on Sodium Haemostasis. Factors such as preoperative Bendroflumethiazide and enthusiastic nursing regimes to encourage oral water intake were found to be contributory factors. Our results suggest that anaesthetists should be aware of post operative hyponatreamia in these patients and a more cautious approach to fluid management is required in the perioperative period.

60 out of total series of 643 metal-on-metal hip replacements, carried out over the last nine years, have so far required revision, 13 for peri-prosthetic fracture and 47 for extensive, symptomatic, peri-articular soft-tissue changes.

Dramatic corrosion of generally solidly fixed, cemented stems has been observed and is believed to have resulted in the release of high levels of cobalt chrome ions from the stem surface. The contribution of the metal-to-metal articulation is, as yet, unclear.

Not including the fracture cases, plain films have demonstrated little or no abnormality to account for patients’ progressive symptoms. MRI scanning, on the other hand, utilising a technique designed to minimise implant artefact, has correlated very closely with findings at the time of revision surgery.

The histological changes, typified by extensive lymphocytic infiltration and a severe vasculitis leading to, in some cases, extensive tissue necrosis are demonstrated and discussed.

The failure of any of the existing protective mechanisms or regulatory restrictions to identify and limit the exposure of large numbers of patients to unsatisfactory implants has again been demonstrated.

Conventional banking of donated femoral heads has been well documented in the literature. It relies on screening potential donors, providing a storage facility and sterilisation techniques which are not standardised. Stored femoral heads have a finite lifetime and wastage does occur. Prion contamination and malignant potential are present with modern storage techniques.

We report a technique of banking the donor’s femoral head in a surgically fashioned subperiosteal pouch, under iliacus. Young patients requiring a total hip replacement who are likely to need revision at a later date are suitable candidates. Patients who have signs of loosening of their total hip replacement and contralateral osteoarthritis are also suitable. The femoral head is retrieved and used for the donor’s own revision surgery. Interim clinical results for 12 patients with the head harvested at a maximum of 5 years from implantation are presented. We report no morbidity at the pouch site and present radiographic results showing good integration of the morselised femoral head bone graft in revision hip surgery. Histological results are also presented.

Autobanking of the patient’s own femoral head has the advantage of providing a graft with a reduced risk of infection, rich in growth factors, with the potential of osteoinduction. It eliminates the need for a storage facility, screening programme and provides a portable storage facility if the patient moves area.

We describe the use of MRI to establish the exact diagnosis in a swollen elbow in a neonate. Urgent diagnosis was needed for medical and social reasons. We accomplished this without the use of an invasive procedure or anaesthesia for a fracture that is recognised to be difficult to diagnose in patients of this age group.