Patients with osteoarthritis undergoing knee replacement have been reported to have an overall reduced mortality compared with that of the general population. This has been attributed to the selection of healthier patients for surgery. However, previous studies have had a maximum follow-up time of ten years. We have used information from the Swedish Knee Arthroplasty Register to study the mortality of a large national series of patients with total knee replacement for up to 28 years after surgery and compared their mortality with that of the normal population. In addition, for a subgroup of patients operated on between 1980 and 2002 we analysed their registered causes of death to determine if they differed from those expected. We found a reduced overall mortality during the first 12 post-operative years after which it increased and became significantly higher than that of the general population. Age-specific analysis indicated an inverse correlation between age and mortality, where the younger the patients were, the higher their mortality. The shift at 12 years was caused by a relative over-representation of younger patients with a longer follow-up. Analysis of specific causes of death showed a higher mortality for cardiovascular, gastrointestinal and urogenital diseases. The observation that early onset of osteoarthritis of the knee which has been treated by total knee replacement is linked to an increased mortality should be a reason for increased general awareness of health problems in these patients

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1–L4 spinal region using dual X-ray absorptiometry. In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men. Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee

We performed Kawamura's dome osteotomy of the pelvis, with simultaneous distal transfer of the greater trochanter on 101 hips in 91 patients with osteoarthritis secondary to hip dysplasia. The mean age at operation was 30 years (15 to 55), and follow-up was for a mean of 8.3 years (5 to 14). Clinical evaluation using the Merle d'Aubigne score showed 92% excellent or good results. Radiologically, 91 hips had good acetabular remodelling and showed no signs of progression of osteoarthritis. In ten hips the osteoarthritic process progressed despite the osteotomy and six of these eventually underwent total hip replacement. Factors which were significantly associated with a poor outcome included an advanced stage of osteoarthritis, valgus deformity of the proximal femur, old age at the time of operation and postoperative persistence of abductor insufficiency

Proximal tibial osteotomy is commonly performed for osteoarthritis of the knee with deformity. The results of 105 dome osteotomies have been reviewed at a minimum follow-up of one year and an average of 4.8 years. Before operation all the knees were painful, 50.5% severely; a further 45.7% disturbed sleep at night. At review 15.2% of knees were free of pain and 60% had only slight pain which did not restrict activity. The preoperative range of movement was maintained and there was only a slight tendency for radiological changes to progress, with actual improvement in some cases. No correlation was found between the correction of deformity to physiological valgus and the result. We cannot explain why tibial osteotomy produces such useful and sustained pain relief

The results of 757 intertorchanteric osteotomies for osteoarthritis of the hip carried out between 1958 and 1970 were reviewed. After osteotomy the joint space in two thirds of the hips was increased and a similar proportion experienced relief of pain lasting at least five years. However, the effect of the osteotomy declined after some ten years; only a quarter of the hips had a lasting "good result" as defined in this investigation. The best results were obtained in active patients under 70 years of age with unilateral hip disease in which a fair range of movement had been preserved despite some shortening and where the radiographs showed loss of joint space with a break in Shenton's line. In this study a displaced osteotomy fixed with a spline emerged as the most successful surgical technique

We have followed up a series of total hip arthroplasties performed for secondary osteoarthritis and analysed the results in relation to the osteoblastic response to the disease. This was assessed pre-operatively from the radiographic appearance, according to Bombelli's criteria (1983). Of 63 hips in 55 patients followed up for five to 13 years, 17 were hypertrophic, 24 normotrophic and 22 atrophic in type. The atrophic-type hips showed a high incidence of acetabular loosening, leading to unsatisfactory clinical results in 32%. By contrast, the hypertrophic-type hips had a low incidence of acetabular loosening, while the normotrophic type showed intermediate results. It was concluded that the osteoblastic response to osteoarthritis is closely related to acetabular loosening and to late clinical failure

Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage

A 10-year-old boy who sustained a fracture through a cyst in the ulna later developed a pseudarthrosis. During 13 years' follow-up the characteristic short bowed forearm developed but, instead of the more usual spontaneous dislocation of the head of the radius, the patient also developed the previously unreported complication of osteoarthritis of the elbow

1. Almost all patients with osteoarthritis of the hip who consult the surgeon do so because they wish to be relieved of pain. They all have limitation of movement in varying degrees but most of them will be either unaware of it or will have accepted it. What is more important, they would not have sought medical advice because of stiffness if there had been no pain. The primary objective of operative treatment must therefore be to relieve pain. 2. Displacement osteotomy will give substantial relief from pain in a high proportion of cases and the relief is lasting. Perhaps that explains why this operation, advocated by McMurray and Malkin twenty-five years ago, is being practised more widely than ever to-day while its competitors (neurectomy, capsulectomy, arthroplasty) have steadily diminished in popularity. 3. The disadvantages of the operation are all related to post-operative immobilisation in plaster, which may induce further stiffness of the hip, even to the extent of ankylosis, or stiffness and pain in the knee. These disadvantages may be overcome to a considerable degree by internal fixation followed by sling suspension and early active movement. But when, under anaesthesia, the range of hip flexion is reduced to 45 degrees or less, the operation is always liable to result in ankylosis, and it is wise in these circumstances to take this possibility into account and warn the patient beforehand

1. Double osteotomy was performed on 1 50 knees between 1961 and 1969. The first fifty-seven cases were assessed independently. 2. The operation of osteotomy of the upper end of the tibia and the lower end of the femur is described. it is emphasised that the osteotomy sites are close to the bone ends and well within the cancellous expansion. 3. The indications for the operation are pain and loss of function in a mobile arthritic knee joint. 4. Flexion of the knee is important during the operation to allow the popliteal artery to be moved away from bone. Arteriograms at necropsy show the danger of damaging the popliteal artery when the knee is extended. 5. The operation appears to be equally effective in osteoarthritis and rheumatoid arthritis. The proliferated synovium of the active rheumatoid knee regresses rapidly following operation. 6. The operation has resulted in relief of pain and increase in function in many knees which had no deformity. When a deformity did exist before operation recurrence of the deformity did not appear to influence the result. 7. The cause of relief of symptoms after osteotomy is not known, and it is suggested that answers to the following questions should be sought: Why are some arthritic knees painful and some not ? Why does physiotherapy relieve pain ? Why does osteotomy relieve pain? Why is double osteotomy followed by regression of synovial proliferation ? Why does osteotomy sometimes fail ? Would osteotomy of one bone (tibia or femur) be sufficient?

1. Experimental evidence is advanced to suggest that the effect of the McMurray displacement osteotomy in osteoarthritis of the hip is to diminish the load carried by the head of the femur, firstly by correction of deformity, and secondly by a "pelvic support" action. 2. A review of seventy-five cases has revealed certain important details in selection and operative management. The end-results indicate that the operation, when correctly performed, is successful in relieving pain and diminishing disability

We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact

We studied the mechanical properties of cartilage from the apparently unaffected compartment of knees with unicompartmental osteoarthritis (OA). Plugs of cartilage and subchondral bone, 8 mm in diameter, were obtained from the tibial plateau of seven patients treated by total knee replacement. Control specimens were obtained from eight cadaver knees of similar age. Specimens were loaded by a plane-ended indentor in a hydraulic materials testing machine; we measured thickness, 'softness', rate of creep, and compressive strength of the articular cartilage. We found that the 'unaffected' cartilage from OA knees was significantly thinner and softer than control cartilage, and it was slightly, although not significantly, weaker. We conclude that the apparently unaffected cartilage in knees with unicompartmental OA is mechanically inferior to normal cartilage, even although clinically, radiologically and morphologically it appears to be sound

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (. sd. ) as endpoints. The Constant score was found to improve from a mean of 26.8 (. sd. 10.3) pre-operatively to 57.6 (. sd. 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (. sd. 27.4) pre-operatively to 125° (. sd. 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (. sd. 6.5) pre-operatively to 30.3° (. sd. 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years. Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years

Of 34 consecutive proximal tibial osteotomies for secondary degenerative arthritis in patients under 40 years of age, 33 were evaluated at least three years (mean 7.5 years) after operation. In all 73% were satisfactory, with four failures in 21 procedures in men and five failures in 12 procedures in women. The primary abnormalities were medial meniscectomy (11), medial and lateral meniscectomy (4), osteochondritis dissecans (3), osteochondritis dissecans with medial meniscectomy (4) and fracture (11). All four knees with both medial and lateral meniscectomy had unsatisfactory results despite obtaining anatomical alignment. Eight patients needed subsequent surgery; five of them had total knee replacement, four within four years of the osteotomy. Proximal tibial osteotomy in younger patients with secondary arthritis gives similar results to those for older patients with primary osteoarthritis. If it fails, this is generally within the first four years after the operation

Primary osteoarthritis of the ankle with no history of trauma is rare. We report the use of a low tibial osteotomy on 18 ankles in 18 patients, two men and 16 women. The osteotomy is designed to correct the varus tilt and anterior opening of the distal tibial joint surface where it has been shown by weight-bearing radiographs and arthroscopy that there is healthy articular cartilage on the lateral side of the ankle. An opening-wedge osteotomy was used to achieve slight overcorrection. Follow-up of the 18 ankles at an average of 6 years 11 months (2.7 to 12.10) showed the results by our own scoring system to be excellent in six ankles, good in nine, and fair in three with no poor results. Of the three patients with fair results, two had been undercorrected and the third had little residual articular cartilage. Arthroscopic examination of ten ankles showed repair by fibrocartilage in seven. We conclude that slight overcorrection of deformity by low tibial osteotomy is effective in treating intermediate-stage primary osteoarthritis of the ankle

Between 1995 and 1997 we undertook 40 bipolar hip arthroplasties in 35 patients with dysplastic osteoarthritis. The steep and shallow acetabulum was excavated and the bipolar socket was placed high with an adjustment of leg-length. At follow-up of between five and seven years, there were 19 excellent, 16 good and five fair results according to the scoring system of Merle d’Aubigné and Postel. The mean radiographic superior migration of the bipolar socket was 2.1 mm (0 to 10). Osteolysis was noted in three hips within three years of the operation. Abduction on weight-bearing was recorded in 24 hips and the bipolar system was found to be functioning predominantly between the inner bearing and the metal femoral head in 20

The relationship between heterotopic bone formation and the morphological type of osteoarthritis was examined after 43 hip replacements. Of the 43 hips studied, nine were atrophic, 19 were normotrophic, and 15 were hypertrophic. The incidence of heterotopic bone formation in the atrophic type was 11%, in the normotrophic type 32%, and in the hypertrophic type 87%. The difference between each type was statistically significant (p less than 0.001)

The Oxford Knee, a resurfacing prosthesis with a meniscal bearing, can be used for either bicompartmental or unicompartmental arthritis. The first 103 unicompartmental cases are presented at a mean time since operation of 36 months (range 21 to 56 months). In those cases with surviving arthroplasties, pain was relieved in 96%. The full range of pre-operative flexion was maintained and flexion deformity was improved from a mean of 6.7 to 5.4 degrees. Stability and alignment were restored to normal in nearly all the knees. Absence of the anterior cruciate ligament was associated with a significantly greater incidence of failure. Six failures occurred in 37 knees lacking a normal anterior cruciate ligament (16.2%); three occurred in 63 knees with a normal anterior cruciate ligament (4.8%) (p less than 0.02). Criteria for the future selection of patients have been deduced from our experience. The operation is recommended for knees with severe unicompartmental osteoarthritis in which all the ligaments are still intact