Eighty-one patients treated by patellectomy for osteoarthritis have been reviewed. Eighty-seven knees were examined with a mean follow-up period of six and a half years. Clinical and radiological assessment was carried out and the results have been analysed. A good result was achieved in 53 per cent, a fair result in 26 per cent and a poor result in 21 per cent. The overall result did not deteriorate significantly with time and the radiological appearance of the tibiofemoral joint deteriorated minimally. Pain before operation, radiological changes at the patellofemoral and tibiofemoral joints and the duration of immobilisation after operation were analysed against the end-result. The only factor before operation that indicated a good prognosis was a minimal radiological change at the tibiofemoral joint. Immobilisation for at least three weeks after operation appeared to be beneficial

Socket migration and rotation in the Charnley total hip replacement were evaluated by roentgen stereophotogrammetric analysis in 23 patients with rheumatoid arthritis and 23 patients with osteoarthritis. The two groups were matched with regard to age and sex. The follow-up time was two years. In the rheumatoid patients socket migration was most prominent in the proximal direction and averaged 0.6 mm at 24 months as compared with 0.1 mm in the osteoarthritic group (p = 0.0003). Within the rheumatoid group a preoperative acetabular protrusion in five patients was associated with increased migration and rotation in all directions. The increased proximal migration in rheumatoid arthritis was consistent (p = 0.0009) even after the exclusion of the five protrusion cases. In the rheumatoid patients there was a correlation between low body-weight and proximal migration, but there was no such correlation in the osteoarthritic group. Our results suggest that socket fixation is less secure in patients with advanced inflammatory arthritis

Many different designs of total hip arthroplasty (THA) with varying performance and cost are available. The identification of those which are the most cost-effective could allow significant cost-savings. We used an established Markov model to examine the cost effectiveness of five frequently used categories of THA which differed according to bearing surface and mode of fixation, using data from the National Joint Registry for England and Wales. Kaplan–Meier analyses of rates of revision for men and women were modelled with parametric distributions. Costs of devices were provided by the NHS Supply Chain and associated costs were taken from existing studies. Lifetime costs, lifetime quality-adjusted-life-years (QALYs) and the probability of a device being cost effective at a willingness to pay £20 000/QALY were included in the models.

The differences in QALYs between different categories of implant were extremely small (<  0.0039 QALYs for men or women over the patient’s lifetime) and differences in cost were also marginal (£2500 to £3000 in the same time period). As a result, the probability of any particular device being the most cost effective was very sensitive to small, plausible changes in quality of life estimates and cost.

Our results suggest that available evidence does not support recommending a particular device on cost effectiveness grounds alone. We would recommend that the choice of prosthesis should be determined by the rate of revision, local costs and the preferences of the surgeon and patient.

Cite this article: Bone Joint J 2015;97-B:449–57.

We report the technique and results of a new method of debridement arthroplasty for advanced primary osteoarthritis of the elbow. Triceps and the periosteum of the olecranon are reflected towards the ulnar side and the joint is opened by dividing the radial collateral ligament. Osteophytes are removed, the olecranon and coronoid fossae are deepened and the fibrosed anterior joint capsule is excised. The degenerative changes are always more advanced on the radial side, with erosion of the capitellum, and it is usually necessary to remodel the head of the radius. In 29 elbows reviewed at a mean of 64 months, the average gain of range of motion was 34 degrees, with good pain relief and improved grip in most patients. Two elbows required reoperation but there were no other serious complications

We have made a retrospective comparison between the results of 49 high tibial osteotomies and 42 unicompartmental replacement arthroplasties performed for the treatment of osteoarthritis of the knee, assessed 5 to 10 years after operation. The type of operation depended on the policy of the consultant responsible for treatment but analysis of the pre-operative findings showed that the two groups were sufficiently similar for direct comparison between them. In the replacement group, 32 (76%) were good, 4 were fair, 3 were poor and 3 had been revised. In the osteotomy group 21 (43%) were good, 11 were fair, 7 were poor and 10 had been revised. It was concluded that, in this series, the results of unicompartmental replacement were significantly better and that this group had shown no sign of late deterioration

We describe a model which can be used for in vitro biocompatibility assays of biomaterials. We studied the in vitro response of human osteoarthritis or rheumatoid arthritis fibroblast-like synoviocytes to Al. 2. O. 3. or ZrO. 2. particles by analyzing the production of interleukin-1 (IL-1) and interleukin-6 (IL-6) and the metabolism of arachidonic acid via lipoxygenase and cyclo-oxygenase pathways. Our results show that, in these cells and under our experimental conditions, Al. 2. O. 3. and ZrO. 2. did not significantly modify the synthesis of IL-1 and IL-6 or the metabolism of arachidonic acid

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

1. A study of normal and osteoarthritic hyaline cartilage has been made with the electron microscope and x-ray diffraction.

2. Normal cartilage consists of a three-dimensional network of collagen fibrils with no preferred orientation, surrounded by a matrix containing polysaccharide.

3. In the osteoarthritic joint the collagen fibrils show definite orientation and a decreased proportion of ground substance. X-ray diffraction confirms this and shows the orientation to be at right angles to the surface of the femoral head.

4. Tensional forces across the joint may explain why osteoarthritic changes first appear in the non-weight-bearing area of the joint.

The aim of this study was to examine the loading of the other joints of the lower limb in patients with unilateral osteoarthritis (OA) of the knee. We recruited 20 patients with no other symptoms or deformity in the lower limbs from a consecutive cohort of patients awaiting knee replacement. Gait analysis and electromyographic recordings were performed to determine moments at both knees and hips, and contraction patterns in the medial and lateral quadriceps and hamstrings bilaterally. The speed of gait was reduced in the group with OA compared with the controls, but there were only minor differences in stance times between the limbs. Patients with OA of the knee had significant increases in adduction moment impulse at both knees and the contralateral hip (adjusted p-values: affected knee: p < 0.01, unaffected knee p = 0.048, contralateral hip p = 0.03), and significantly increased muscular co-contraction bilaterally compared with controls (all comparisons for co-contraction, p < 0.01).

The other major weight-bearing joints are at risk from abnormal biomechanics in patients with unilateral OA of the knee.

Cite this article: Bone Joint J 2013;95-B:348–53.

We compared the five- to seven-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing with a hybrid total hip arthroplasty in two groups of 54 hips, matched for gender, age, body mass index and activity level.

Function was excellent in both groups, as measured by the Oxford hip score, but the Birmingham hip resurfacings had higher University of California at Los Angeles activity scores and better EuroQol quality of life scores. The total hip arthroplasties had a revision or intention-to-revise rate of 8%, and the Birmingham hip resurfacings of 6%. Both groups demonstrated impending failure on surrogate end-points. Of the total hip arthroplasties, 12% had polyethylene wear and osteolysis under observation, and 8% of Birmingham hip resurfacings showed migration of the femoral component. Polyethylene wear was present in 48% of the hybrid hips without osteolysis. Of the femoral components in the Birmingham hip resurfacing group which had not migrated, 66% had radiological changes of unknown significance.

Dysplasia of the hip, hypotonia, osteopenia, ligamentous laxity, and mental retardation increase the complexity of performing and managing patients with Down syndrome who require total hip replacement (THR). We identified 14 patients (six males, eight females, 21 hips) with Down syndrome and degenerative disease of the hip who underwent THR, with a minimum follow-up of two years from 1969 to 2009. In seven patients, bilateral THRs were performed while the rest had unilateral THRs. The mean clinical follow-up was 5.8 years (standard deviation (sd) 4.7; 2 to 17). The mean Harris hip score was 37.9 points (sd 7.8) pre-operatively and increased to 89.2 (sd 12.3) at final follow-up (p = 1x10^-9). No patient suffered a post-operative dislocation. In three patients, four hips had revision THR for aseptic loosening at a mean follow-up of 7.7 years (sd 6.3; 3 to 17). This rate of revision THR was higher than expected. Our patients with Down syndrome benefitted clinically from THR at mid-term follow-up.

Cite this article: Bone Joint J 2014;96-B:1455–8.

1. The cause of cyst formation lies in the major overloading of certain regions caused by the unevenness of the articular surface produced by the arthritic process.

2. Photoelasticity investigations disclose an overburdening of the bone beneath the surface of the joint, which in turn markedly resembles the shapes of actual cysts.

3. The results of this investigation fit organically into the logical sequence of processes in accordance with our theory.

4. This theory is further borne out by the successful formation of cyst phenomena in healthy joints by overloading (Trias 1961).

5. Our theory has no immediate practical bearing on the treatment of arthritic cysts. However, it uncovers certain interesting aspects of the behaviour of bone tissues under mechanical overloading above the limits of biological, though below those of mechanical bearing capacity. Conclusions arising therefrom might in many respects be useful in research into the physiology of bone.

1. An attempt has been made to correlate the radiographic appearances and the morbid anatomy of the cystic changes that occur in the head of the femur in advanced osteoarthritis.

2. The suggestion is made that these lesions are foci of traumatic bone necrosis. Repair may be complicated by the subsequent entrance of synovial fluid through defects in the surface.

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery.

Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.