We report the survival, radiological and functional outcomes of a single surgeon series of his first 144 consecutive Birmingham hip resurfacing procedures (130 patients) at a minimum of ten years. There were ten revisions during this time. Although no patients were lost to follow-up some did not complete the scoring assessment or undergo radiological assessment at ten years.

The ten-year survival for male patients was 98.0% (95% confidence interval 95.2 to 100). The ten-year survival for the total cohort with aseptic revision as the endpoint was 95.5% (95% confidence interval 91.8 to 99.0) and including revisions for sepsis was 93.5% (95% confidence interval 89.2 to 97.6). The median modified Oxford hip score at ten years was 4.2% (interquartile range 0 to 19) and the median University of California, Los Angeles score was 7.0 (interquartile range 5.0 to 8.0).

This study confirms the midterm reports that metal-on-metal hip resurfacing using the Birmingham Hip provides a durable alternative to total hip replacement, particularly in younger male patients wishing to maintain a high level of function, with low risk of revision for at least ten years.

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature.

Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.

The management of joint replacement in lysosomal storage diseases has not been well reported. We present three patients with progressive degenerative changes of the hips who required bilateral total hip replacement in early childhood. The stature of the patients make it essential to have access to appropriately scaled prostheses. Consideration has to be given to associated disorders of the skeleton which must be carefully screened to ensure safety in providing appropriate anaesthesia as well as ensuring that there is no cardiac abnormality. In one patient, a periprosthetic fracture was sustained in one hip in the early post-operative course requiring internal fixation.

The patient made a full recovery and all six hips were clinically and radiologically satisfactory at mid-term review.

We compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings.

Survival at five years using revision surgery as an endpoint, was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the non-obese group (p < 0.001). The morbidly obese patients had a higher rate of complications (22% vs 5%, p = 0.012), which included dislocation and both superficial and deep infection.

In light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life.

Bone preservation and physiological distribution of forces on the proximal femur are key elements in introducing a successful uncemented total hip replacement. In order to achieve this, in the mid 1990s, we developed an ultra short proximal loading custom-made component with a lateral flare, a high femoral neck osteotomy and without a diaphyseal stem.

We report the outcome of 129 custom-made hydroxyapatite-coated uncemented short femoral components inserted into 109 patients between June 1995 and May 2004. The mean age of the patients was 51 years (21 to 71) and the mean follow-up was eight years (4.9 to 14.1). Bone behaviour around the implant was studied on the post-operative radiographs. The mean Harris hip score improved from 44 (8 to 66) pre-operatively to 95 (76 to 100) at final follow-up. The Western Ontario MacMaster University Osteoarthritis index was 93 of 100 at final review. None of the patients reported thigh pain. A total of five hips were revised, three for polyethylene liner exchange and two for complete revision of the acetabular component. No femoral components were revised. The radiological changes in the proximal femur were generally good, as evidenced by spot welds both on the medial and lateral aspects of the femur. No component migrated. The presence of a lateral flare and use of a high osteotomy of the femoral neck provided good clinical and radiological results. The absence of a diaphyseal portion of the stem did not impair stability.

We performed a prospective, randomised trial of 44 patients to compare the functional outcomes of a posterior-cruciate-ligament-retaining and posterior-cruciate-ligament-substituting total knee arthroplasty, and to gain a better understanding of the in vivo kinematic behaviour of both devices.

At follow-up at five years, no statistically significant differences were found in the clinical outcome measurements for either design. The prevalence of radiolucent lines and the survivorship were the same. In a subgroup of 15 knees, additional image-intensifier analysis in the horizontal and sagittal planes was performed during step-up and lunge activity. Our analysis revealed striking differences. Lunge activity showed a mean posterior displacement of both medial and lateral tibiofemoral contact areas (roll-back) which was greater and more consistent in the cruciate-substituting than in the cruciate-retaining group (medial p < 0.0001, lateral p = 0.011). The amount of posterior displacement could predict the maximum flexion which could be achieved (p = 0.018). Forward displacement of the tibiofemoral contact area in flexion during stair activity was seen more in the cruciate-retaining than in the cruciate-substituting group. This was attributed mainly to insufficiency of the posterior cruciate ligament and partially to that of the anterior cruciate ligament. We concluded that, despite similar clinical outcomes, there are significant kinematic differences between cruciate-retaining and cruciate-substituting arthroplasties.

Between 1990 and 2000, 123 hips in 110 patients were reconstructed for aseptic loosening using impaction bone grafting with frozen, irradiated, morsellised femoral heads and cemented acetabular components. This series was reported previously at a mean follow-up of five years. We have extended this follow-up and now describe the outcome of 86 hips in 74 patients at a mean of ten years. There have been 19 revisions, comprising nine for infection, seven for aseptic loosening and three for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 of 67 hips (95.5%).

Survival analysis for all indications at ten years was 83.3% (95% confidence interval (CI) 68 to 89) and 71.3% (95% CI 58 to 84) at 15 years.

Acetabular reconstruction using irradiated allograft and a cemented acetabular component is an effective method of reconstruction, providing results in the medium- to long-term comparable with those of reported series where non-irradiated freshly-frozen bone was used.

The Morquio syndrome is a rare disorder which presents with a number of musculoskeletal problems. The literature describing total knee replacement in these patients is sparse. We describe the management of a patient with bilateral instability and pain in the knees using bilateral constrained knee replacements, and followed up for five years with pre- and postoperative knee scores. We highlight the difficulties encountered and discuss the end results.

We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient.

Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.

We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots.

Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots.

We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts.

We review the treatment of pelvic Ewing’s sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods.

We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100).

We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing’s sarcoma.

The Salter innominate osteotomy has been used successfully for many years in the treatment of developmental dysplasia of the hip. One of its main drawbacks is the need for internal fixation with pins and their subsequent removal. We describe a modification of this osteotomy that does not require pin fixation and secondary removal. We retrospectively reviewed 114 hips in 94 patients who had been operated on by a single surgeon. An oblique rather than the original horizontal osteotomy was used without internal fixation. There were 80 female and 14 male patients. The mean age at operation was 25 months (18 to 84) and the mean follow-up was 30 months (12 to 88). Most patients required additional open reduction and capsuloplasty. The mean pre-operative acetabular index was 37.9° (24° to 54°), which decreased to 19.9° (7° to 29°) in the immediate post-operative period, and improved to 14.6° (5° to 25°) at the final follow-up (student’s t-test, p < 0.0001).

We believe that by changing the direction of the osteotomy line, it is possible to avoid pin fixation. The radiological outcomes are comparable to those of the original technique, but longer follow-up will be necessary.

We identified 148 patients who had undergone a revision total knee replacement using a single implant system between 1990 and 2000. Of these 18 patients had died, six had developed a peri-prosthetic fracture and ten had incomplete records or radiographs. This left 114 with prospectively-collected radiographs and Bristol knee scores available for study. The height of the joint line before and after revision total knee replacement was measured and classified as either restored to within 5 mm of the pre-operative height or elevated if it was positioned more than 5 mm above the pre-operative height. The joint line was elevated in 41 knees (36%) and restored in 73 (64%).

Revision surgery significantly improved the mean Bristol knee score from 41.1 (sd 15.9) pre-operatively to 80.5 (sd 15) post-operatively (p < 0.001). At one year post-operatively both the total Bristol knee score and its functional component were significantly better in the restored group than in the elevated group (p < 0.01). Overall, revision from a unicondylar knee replacement required less use of bone graft, fewer component augments, restored the joint line more often and gave a significantly better total Bristol knee score (p < 0.02) and functional score (p < 0.01) than revision from total knee replacement.

Our findings show that restoration of the joint line at revision total knee replacement gives a significantly better result than leaving it unrestored by more than 5 mm. We recommend the greater use of distal femoral augments to help to achieve this goal.

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up.

On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term.

We have examined the relationship between the size of the flexion gap and the anterior translation of the tibia in flexion during implantation of a posterior cruciate ligament (PCL)-retaining BalanSys total knee replacement (TKR). In 91 knees, the flexion gap and anterior tibial translation were measured intra-operatively using a custom-made, flexible tensor-spacer device.

The results showed that for each increase of 1 mm in the flexion gap in the tensed knee a mean anterior tibial translation of 1.25 mm (SD 0.79, 95% confidence interval 1.13 to 1.37) was produced.

When implanting a PCL-retaining TKR the surgeon should be aware that the tibiofemoral contact point is related to the choice of thickness of the polyethylene insert. An additional thickness of polyethylene insert of 2 mm results in an approximate increase in tibial anterior translation of 2.5 mm while the flexed knee is distracted with a force of between 100 N and 200 N.

We have evaluated the quality of life and functional outcome after unilateral primary total hip replacement (THR). Between 5 January 1998 and 31 July 2000, we recruited a consecutive series of 627 patients undergoing this procedure and investigated them prospectively. Each was assessed before operation and reviewed after six months, 18 months, three years and five years. The Short Form-36 Health Survey (SF-36) and Harris Hip scores were evaluated at each appointment.

All dimensions of the SF-36 except for mental health and general health perception, improved significantly after operation and this was maintained throughout the follow-up. The greatest improvement was seen at the six-month assessment. On average, women reported lower SF-36 scores pre-operatively, but the gender difference did not continue post-operatively. The Harris Hip scores improved significantly after operation, reaching a plateau after 18 months. The improved quality of life was sustained five years after THR.

Since the introduction of the first National Arthroplasty Register in Sweden in 1975, many other countries have tried to adopt the successful Scandinavian system. However, not all have overcome the political and practical difficulties of establishing a working register. We have surveyed the current registries to establish the key factors required for an effective database. We have received detailed information from 15 arthroplasty registers worldwide. The legal conditions under which they operate together with the methods of collection and handling of the data differ widely, but the fulfilment of certain criteria is necessary achieve a high degree of completeness of the data to ensure the provision of statistically relevant information.

This study describes 146 primary total knee replacements, either fully or partially coated with hydroxyapatite of which 74 knees in 68 patients were available for clinical and radiological assessment at a mean of 11.2 years (10 to 15). The global failure rate was 1.37% and survival rate with mechanical failure as the end-point was 98.14%. Radiological assessment indicated intimate contact between bone and the hydroxyapatite coating. Over time the hydroxyapatite coating appears to encourage filling of interface gaps remaining after surgery. Our results compare favourably with those of series describing cemented or porous-coated knee replacements, and suggest that fixation with hydroxyapatite is a reliable option in primary total knee replacement.

We have developed a CT-based navigation system using infrared light-emitting diode markers and an optical camera. We used this system to perform cementless total hip replacement using a ceramic-on-ceramic bearing couple in 53 patients (60 hips) between 1998 and 2001. We reviewed 52 patients (59 hips) at a mean of six years (5 to 8) postoperatively. The mid-term results of total hip replacement using navigation were compared with those of 91 patients (111 hips) who underwent this procedure using the same implants, during the same period, without navigation. There were no significant differences in age, gender, diagnosis, height, weight, body mass index, or pre-operative clinical score between the two groups. The operation time was significantly longer where navigation was used, but there was no significant difference in blood loss or navigation-related complications. With navigation, the acetabular components were placed within the safe zone defined by Lewinnek, while without, 31 of the 111 components were placed outside this zone. There was no significant difference in the Merle d’Aubigne and Postel hip score at the final follow-up. However, hips treated without navigation had a higher rate of dislocation. Revision was performed in two cases undertaken without navigation, one for aseptic acetabular loosening and one for fracture of a ceramic liner, both of which showed evidence of neck impingement on the liner. A further five cases undertaken without navigation showed erosion of the posterior aspect of the neck of the femoral component on the lateral radiographs. These seven impingement-related mechanical problems correlated with malorientation of the acetabular component. There were no such mechanical problems in the navigated group.

We conclude that CT-based navigation increased the precision of orientation of the acetabular component and control of limb length in total hip replacement, without navigation-related complications. It also reduced the rate of dislocation and mechanical problems related to impingement.

A modular layered acetabular component (metal-polyethylene-ceramic) was developed in Japan for use in alumina ceramic-on-ceramic total hip replacement. Between May 1999 and July 2000, we performed 35 alumina ceramic-on-ceramic total hip replacements in 30 consecutive patients, using this layered component and evaluated the clinical and radiological results over a mean follow-up of 5.8 years (5 to 6.5). A total of six hips underwent revision, one for infection, two for dislocation with loosening of the acetabular component, two for alumina liner fractures and one for component dissociation with pelvic osteolysis. There were no fractures of the ceramic heads, and no loosening of the femoral or acetabular component in the unrevised hips was seen at final follow-up. Osteolysis was not observed in any of the unrevised hips. The survivorship analysis at six years after surgery was 83%. The layered acetabular component in our experience, has poor durability because of unexpected mechanical failures including alumina liner fracture and component dissociation.