Patient specific cutting guides generated by preoperative Magnetic Resonance Imaging (MRI) of the patient’s extremity have been proposed as a method of improving the consistency of Total Knee Arthroplasty (TKA) alignment and adding efficiency to the operative procedure. The cost of this option was evaluated by quantifying the savings from decreased operative time and instrument processing costs compared to the additional cost of the MRI and the guide. Coronal plane alignment was measured in an unselected consecutive series of 200 TKAs, 100 with standard instrumentation and 100 with custom cutting guides. While the cutting guides had significantly lower total operative time and instrument processing time, the estimated $322 savings was overwhelmed by the $1,500 additional cost of the MRI and the cutting guide. All measures of coronal plane alignment were equivalent between the two groups. The data does not currently support the proposition that patient specific guides add value to TKA.

Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.

The purpose of this paper is to discuss the risk factors, prevention strategies, classification, and treatment of intra-operative femur fractures sustained during primary and revision total hip arthroplasty.

Improvements in the surgical technique of total knee replacement (TKR) are continually being sought. There has recently been interest in three-dimensional (3D) pre-operative planning using magnetic resonance imaging (MRI) and CT. The 3D images are increasingly used for the production of patient-specific models, surgical guides and custom-made implants for TKR.

The users of patient-specific instrumentation (PSI) claim that they allow the optimum balance of technology and conventional surgery by reducing the complexity of conventional alignment and sizing tools. In this way the advantages of accuracy and precision claimed by computer navigation techniques are achieved without the disadvantages of additional intra-operative inventory, new skills or surgical time.

This review describes the terminology used in this area and debates the advantages and disadvantages of PSI.

A moderator and panel of five experts led an interactive session in discussing five challenging and interesting patient case presentations involving surgery of the hip. The hip pathologies reviewed included failed open reduction internal fixation of subcapital femoral neck fracture, bilateral hip disease, evaluation of pain after metal-on-metal hip arthroplasty, avascular necrosis, aseptic loosening secondary to osteolysis and polyethylene wear, and management of ceramic femoral head fracture.

Between December 2004 and June 2006, 136 patients (156 total hip replacements), were sent from the waiting list of the Cardiff Vale NHS Trust to the NHS Treatment Centre, Weston-super-Mare, in an attempt to reduce the waiting time for total hip replacement. Because of concerns about their outcome, each patient was contacted and invited to attend a review appointment with a consultant specialising in hip and revision hip replacement.

A total of 98 patients (113 hips) were reviewed after a mean of 23 months (11 to 30). There were 104 cemented hips, seven hybrid and two cementless. An acetabular inclination of > 55° was seen in 18 (16%). Radiolucent lines around the acetabular component were seen in 76 (67%). The femoral component was in more than 4° of varus in 47 (42%). The medial floor had been breached in 13 (12%) and there was a leg-length discrepancy of more than 1 cm in ten (9%). There were three dislocations, one femoral fracture, one pulmonary embolus, one deep infection and two superficial wound infections.

To date, 13% (15 hips) have been revised and a further 4% (five hips) await revision, mostly for a painful loose acetabular component. The revision rate far exceeds the 0.5% five-year failure rate reported in the Swedish Registry for the components used. This initiative and the consequent need for correction of the problems created, has significantly increased the workload of our unit.

We have reviewed 42 patients who had revision of metal-on-metal resurfacing procedures, mostly because of problems with the acetabular component. The revisions were carried out a mean of 26.2 months (1 to 76) after the initial operation and most of the patients (30) were female.

Malpositioning of the acetabular component resulted in 27 revisions, mostly because of excessive abduction (mean 69.9°; 56° to 98°) or insufficient or excessive anteversion. Seven patients had more than one reason for revision. The mean increase in the diameter of the component was 1.8 mm (0 to 4) when exchange was needed.

Malpositioning of the components was associated with metallosis and a high level of serum ions. The results of revision of the femoral component to a component with a modular head were excellent, but four patients had dislocation after revision and four required a further revision.

We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12).

The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p < 0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components.

Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation.

After placment of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy.

The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (−9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed.

Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length.

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck.

We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years.

Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D.

Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years.

The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.

We compared the performance of uncemented trabecular metal tibial components in total knee replacement with that of cemented tibial components in patients younger than 60 years over two years using radiostereophotogrammetric analysis (RSA). A total of 22 consecutive patients (mean age 53 years, 33 to 59, 26 knees) received an uncemented NexGen trabecular metal cruciate-retaining monobloc tibial component and 19 (mean 53 years, 44 to 59, 21 knees) a cemented NexGen Option cruciate-retaining modular tibial component.

All the trabecular metal components migrated during the initial three months and then stabilised. The exception was external rotation, which did not stabilise until 12 months. Unlike conventional metal-backed implants which displayed a tilting migration comprising subsidence and lift-off from the tibial tray, most of the trabecular metal components showed subsidence only, probably due to the elasticity of the implant.

This pattern of subsidence is regarded as being beneficial for uncemented fixation.

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored.

Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed.

Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

The purpose of this study was to define immediate post-operative ‘quality’ in total hip replacements and to study prospectively the occurrence of failure based on these definitions of quality. The evaluation and assessment of failure were based on ten radiological and clinical criteria. The cumulative summation (CUSUM) test was used to study 200 procedures over a one-year period. Technical criteria defined failure in 17 cases (8.5%), those related to the femoral component in nine (4.5%), the acetabular component in 32 (16%) and those relating to discharge from hospital in five (2.5%). Overall, the procedure was considered to have failed in 57 of the 200 total hip replacements (28.5%). The use of a new design of acetabular component was associated with more failures. For the CUSUM test, the level of adequate performance was set at a rate of failure of 20% and the level of inadequate performance set at a failure rate of 40%; no alarm was raised by the test, indicating that there was no evidence of inadequate performance.

The use of a continuous monitoring statistical method is useful to ensure that the quality of total hip replacement is maintained, especially as newer implants are introduced.

In this paper, we consider wound healing after total knee arthroplasty.

We present a comparison of patient-reported outcomes (PROMs) in relation to patient age, in patients who had received a total (TKR) or unicompartmental knee replacement (UKR). The outcome was evaluated using the Oxford knee score (OKS), EuroQol (EQ-5D) and satisfaction scores. Patients aged 65 to 84 years demonstrated better pre-operative function scores than those aged < 65 years (OKS, p = 0.03; EQ-5D, p = 0.048) and those aged ≥ 85 years (OKS, p = 0.03). Post-operative scores were comparable across age groups, but a linear trend for greater post-operative improvement in OKS and EQ-5D was seen with decreasing age (p < 0.033). The overall mean satisfaction score at six months was 84.9, but those aged <  55 years exhibited a lower mean level of satisfaction (78.3) compared with all other age groups (all p < 0.031). The cumulative overall two-year revision rate was 1.3%. This study demonstrates that good early outcomes, as measured by the OKS and EQ-5D, can be anticipated following knee replacement regardless of the patient’s age, although younger patients gain greater improvement. However, the lower satisfaction in those aged < 55 years is a concern, and suggests that outcome is not fully encapsulated by the OKS and EQ-5D evaluation, and raises the question whether the OKS alone is an appropriate measure of pain and function in younger, more active individuals.

Cite this article: Bone Joint J 2013;95-B:38–44.

The Oxford mobile-bearing unicompartmental knee replacement (UKR) is an effective and safe treatment for osteoarthritis of the medial compartment. The results in the lateral compartment have been disappointing due to a high early rate of dislocation of the bearing. A series using a newly designed domed tibial component is reported.

The first 50 consecutive domed lateral Oxford UKRs in 50 patients with a mean follow-up of three years (2.0 to 4.3) were included. Clinical scores were obtained prospectively and Kaplan-Meier survival analysis was performed for different endpoints. Radiological variables related to the position and alignment of the components were measured.

One patient died and none was lost to follow-up. The cumulative incidence of dislocation was 6.2% (95% confidence interval (CI) 2.0 to 17.9) at three years. Survival using revision for any reason and aseptic revision was 94% (95% CI 82 to 98) and 96% (95% CI 85 to 99) at three years, respectively. Outcome scores, visual analogue scale for pain and maximum knee flexion showed a significant improvement (p < 0.001). The mean Oxford knee score was 43 (sd 5.3), the mean Objective American Knee Society score was 91 (sd 13.9) and the mean Functional American Knee Society score was 90 (sd 17.5). The mean maximum flexion was 127° (90° to 145°). Significant elevation of the lateral joint line as measured by the proximal tibial varus angle (p = 0.04) was evident in the dislocation group when compared with the non-dislocation group.

Clinical results are excellent and short-term survival has improved when compared with earlier series. The risk of dislocation remains higher using a mobile-bearing UKR in the lateral compartment when compared with the medial compartment. Patients should be informed about this complication. To avoid dislocations, care must be taken not to elevate the lateral joint line.

Avascular necrosis of the femoral head creates considerable morbidity in successful renal transplant recipients who are generally young and expect active lifestyles. Total hip replacement is considered the treatment of choice in these patients, but surgeons may be wary because of a supposed increase in the risk of infection and other complications.

A review of the literature reveals that cemented hip arthroplasty provides good to excellent functional outcomes for renal transplant patients. Most authors have found that the risk of infection is not increased despite chronic immunosuppression, but the rates of general complications are and should be anticipated and treated. There is a high rate of early failure in these patients because of their young age and diffuse osteopenia as a result of secondary hyperparathyroidism related to the underlying renal disease and chronic steroid use. Recent studies have found that despite decreased bone stock in these patients, porous-coated prostheses are not contraindicated.