We performed a meta-analysis of modern total joint replacement (TJR) to determine the post-operative mortality and the cause of death using different thromboprophylactic regimens as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran, fondaparinux or rivaroxaban); 3) Potent anticoagulation combined (PAC) with regional anaesthesia and/or pneumatic compression devices (PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional anaesthesia, PCDs and aspirin in low-risk patients. Cause of death was classified as autopsy proven, clinically certain or unknown. Deaths were grouped into cardiopulmonary excluding pulmonary embolism (PE), PE, bleeding-related, gastrointestinal, central nervous system, and others (miscellaneous). Meta-analysis based on fixed effects or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths). The mortality was lowest in the MM (0.2%) and WC (0.2%) groups. The most frequent cause of death was cardiopulmonary (47.9%), followed by PE (25.4%) and bleeding (8.9%). The proportion of deaths due to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%; PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%; PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce the overall mortality or the proportion of deaths due to PE

Limb salvage is now customary in the treatment of primary bone tumours. The proximal tibia is a frequent site for these neoplasms but reconstruction, especially in children, is a formidable challenge. We reviewed 20 children with extendible replacements of the proximal tibia, all with a minimum follow-up of five years. Five died from their disease and, of the remaining 15, four had above-knee amputations for complications. Infection occurred in seven patients; in five it was related to the lengthening procedure. Aseptic loosening is inevitable in the younger children and only two have avoided a revision, amputation or other major complication; both were aged 12 years at the time of the initial surgery. Despite this, 11 children are alive with a functioning leg and a mean Musculoskeletal Tumour Society functional score of 83%. The lengthening mechanisms used in our series required extensive open operations. We are now using a simpler, minimally invasive, technique which we hope will decrease the incidence of complications. At present, the use of extendible prostheses of the proximal tibia remains an experimental procedure

In order to improve the fixation of the stem in primary Charnley low-friction arthroplasty, the medullary canal was routinely closed off with a cancellous bone block. A prospective study of 611 consecutive arthroplasties were carried out between 1 and 5 1/2 years (average 2 years and 9 months) after operation. There were two cases of radiological loosening of the stem, both of which could have been avoided. Five other patients showed demarcation of the bone-cement junction at the calcar; two of these are considered to be "at risk" of loosening. There was no evidence of radiological loosening of the stem in 604 cases and the method is recommended for routine use in primary total hip arthroplasty

We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture

Forty-four patients who had undergone 50 capsular arthroplasties for congenital dislocation of the hip were reviewed after a mean follow-up of 20 years. Their average age at operation was 5.9 years; 31 of the operations were undertaken because of late presentation, the remainder because of the failure of previous surgery. In all, 70% of the hips showed good function despite a reduced range of movement, but patients with bilateral arthroplasties fared poorly. Excellent containment within the acetabulum was found in 80%, but the femoral head was always abnormally high though not unduly lateral or medial. This configuration had remained unchanged during follow-up. The accuracy of reduction along the mediolateral axis was the only variable found to influence the outcome significantly. Functional deterioration, associated with pain, was noted to be more common after 20 years than before, and was associated with radiographic evidence of joint degeneration

We report a prospective study of the use of intramedullary bone blocks to improve the fixation of a matt-finish femoral stem in Charnley low-friction arthroplasties. There were 379 patients (441 hips), but at a minimum follow-up of ten years there were 258 arthroplasties in 221 patients including some which had been revised. The mean age at surgery was 41 years (17 to 51) and the mean follow-up was 13.4 years (1 to 20 including the early revisions). Nine stems (3.5%) had been revised for aseptic loosening, but there were no stem fractures. Survivorship of stems was 99.2% at ten years and 94.35% at 15 and 20 years. We found that the patient’s gender, the position of the stem and the experience of the surgeon all influenced the outcome. Our findings suggest that using our method of stem fixation, follow-up of over 11 years was needed to reveal the effects of endosteal cavitation of the femur, and of over 13 years to assess any divergence between the clinical and the radiological outcomes of stem fixation

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone

Six patients with severe haemophilic arthropathy of the elbow have been treated by limited excision arthroplasty using a sheet of silicone rubber as an interposition membrane. There were no complications. The symptoms and signs before and after operation have been assessed using the grading system advocated recently by the World Federation of Haemophilia. In all cases there was relief of pain and increased movement. Moreover, the subsequent incidence of spontaneous haemorrhage into the elbow has been reduced with considerable cost benefit

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt–chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components. Cite this article: Bone Joint J 2013;95-B:31–7

We reviewed 54 patients at a mean follow-up of 4 years 4 months after rerevisions for failure of Charnley low-friction arthroplasty. Rerevision for aseptic loosening in 26 hips was satisfactory; there were no clinical failures and at the latest radiological assessment only one stem and three sockets showed signs of loosening. By contrast, nine of 20 multiple revisions for recurrent dislocation failed, as did five of eight multiple revisions for deep infection. There was radiological evidence of loosening in one stem and nine sockets in the former group and in three stems and five sockets in the latter

Compression testing of cadaver specimens showed that excision of the radial head allowed proximal radial displacement. The insertion of a metallic radial head restored normal mechanics, while a silicone rubber implant did not. We reviewed 31 of 36 comminuted fractures of the radial head, 21 associated with dislocation or ulnar fracture, which had been treated by primary replacement with a Vitallium prosthesis. At a mean follow-up of 4.5 years, there was reliable restoration of stability and prevention of proximal radial migration. There had been no dislocations or prosthetic failures, but two implants had been removed for loosening. The prosthesis is recommended for use as a spacer to stabilise the elbow after severe injuries while the soft tissues heal

We have endeavoured to make known the results of a simple type of arthroplasty of the hip which is well tolerated even by elderly patients. It has not been the purpose of this article to compare former operations with our own, a newcomer in the field of surgery of the hip. In particular we do not wish to compare our comparatively recent results with Smith-Petersen's well-established method of cup arthroplasty—a magnificent contribution to the surgery of the region. The results we have already obtained, however, appear sufficiently favourable to merit further study and development of the method. If the future confirms the value of our early results, we shall perhaps be able to suggest operation to patients who suffer more from loss of function than from pain

In 20 skeletally mature female merino sheep, divided into four groups, we performed total medial meniscectomy, removal of the middle third of the patellar tendon, and tenotomy of the calcaneal tendon of the right hind leg. Group I (control) had no additional procedures. In the other three groups the medial meniscus was replaced by the middle third of the patellar tendon from the ipsilateral knee. The animals were killed at three (group II), six (group III), or 12 months (group IV) and the tendon-meniscus examined macroscopically, by light and scanning electron microscopy, and biomechanically. Remodelling of the tissue had taken place by 12 months but the failure stress and tensile modulus for the tendon-meniscus were lower than for the normal meniscus. Our evidence suggests that, in sheep, replacement of a meniscus by a tendon autograft may decrease the severity of the degenerative changes that occur after meniscectomy

This is the first time that the principle of the mould—the principle of guiding the repair of nature for the purpose of recreating a destroyed or damaged structure, has been applied to surgery. The evolution of the method to its present encouraging stage is the result of the co-operative, professional family spirit of the Massachusetts General Hospital. We all share in it. We share it with the general surgeon because of his contributions to surgical technique. We share it with the "medical man" because of his pre-operative and post-operative care of the patient; because of his guidance as to when, and when not, to operate; and because of the many friendly arguments which are productive of so much good. We share it with the anaesthetist because of his clinical judgment of the patient, his selection of anaesthetic agent, and his continuous, conscientious administration of the anaesthetic throughout the operation. I am going to change from "we" to "I." I owe so much to my assistants, from the first to the last: Bill Rogers, Eddie Cave, George Van Gorder, Paul Norton, Milton Thompson, Otto Aufranc, and Carroll Larson. I want to thank them all for helping to carry the load, for remembering the things that I forgot, and for making helpful suggestions which often led to improvement in surgical technique or to the construction of a useful instrument. I want to pay tribute to the staff of the Orthopaedic Service of the Massachusetts General Hospital and to thank its members for kindly scepticism, constructive criticism, and neverfailing loyal support. The subject of this lecture, "Evolution of Mould Arthroplasty of the Hip Joint," is appropriate for a Moynihan lecture. It is not the work of one man alone. It is the work of one man, supported by a co-operative, helpful, and friendly hospital staff. This is what Lord Moynihan strove so hard to bring about at a time when surgeons viewed one another as rivals. To quote Dr William Mayo: "It is to Lord Moynihan's everlasting credit that, largely as a result of his unceasing efforts, surgeons came to consider themselves as fellow-workers in a cause."

We reviewed 249 consecutive Charnley primary low-friction arthroplasties in 191 patients performed by one surgeon using a transtrochanteric approach at a minimum follow-up of ten years. Of these, 37 hips in 32 patients showed osteolysis and were compared with 41 hips in 37 matched patients with no osteolysis. We assessed in each case the wear rate, stability of the prosthesis, acetabular angle, socket angle, thickness of the acetabular and femoral cement mantle, canal flare index, femoral score, stem alignment, implant:canal ratio and stem:canal ratio. We found that a high rate of wear, component instability and osteolysis were associated. Osteolysis was three times more common in men than in women. Factors which reduced osteolysis were cement mantles of 6 mm at the acetabulum and of 3 mm in all zones of the femur, a stem:canal ratio of 60% to 70% and an implant:canal ratio of over 99%. The overall incidence of osteolysis was 14.9% but when these technical criteria were met, the incidence was 5.2%. This suggests that careful technique can dramatically reduce the risk of this complication

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions. We have assessed the survivorship, functional outcome and complications of this procedure in patients aged <  50 years through a large longitudinal series with consistent treatment algorithms. Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated. Using further revision for any reason as an end point, the survival of the acetabular component was 71% (. sd. 4) and 54% (. sd. 7) at ten- and 20 years. The survival of the femoral component was 80% (. sd. 4) and 62% (. sd. 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review. This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement. Cite this article: Bone Joint J 2014;96-B:1047–51

Between 1983 and 1988 we carried out 45 Charnley low-friction arthroplasties with autografts from the femoral head in 41 patients for developmental dysplasia of the hip. The preoperative radiographs were assessed for the severity of DDH according to the classifications of Crowe et al, Hartofilakidis et al and Sharp. The postoperative and follow-up radiographs were analysed for coverage of the socket by the graft, for loosening and for the outcome of the fixation of the bone graft. Two patients died (two hips) at four and seven years after THR from causes unrelated to the surgery and were excluded from the final radiological analysis. The mean age of the patients at the time of operation was 46 years 3 months. The autograft of the femoral head covered a mean 26% (16 to 35) of the acetabular component. All the grafts united. Some degree of resorption of the bone graft occurred in 27 patients, and always involved the lateral part of the graft, which was beyond the margin of the socket. After a mean follow-up of 11 years there had been no revisions and 38 patients had no pain or only slight discomfort. One socket migrated and four others were fully demarcated. Our findings indicate that the Charnley LFA with an autograft of the femoral head for DDH remains successful at a follow-up of 15 years

Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates.

In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates.

Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres.

Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection.

There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice.

Cite this article: Bone Joint J 2018;100-B:1264–9.

1. In seventeen cases of tuberculosis of the hip in children with severe destruction of the joint arthroplasty was done using full thickness skin from the abdominal wall as the interposing material. 2. The results, after a follow-up on the average of three years, show that one-third of the cases are very satisfactory, one-third are fair and one-third show no movement

We have reviewed 65 bipolar arthroplasties of the hip in 55 patients with osteoarthritis secondary to dysplasia. The mean age at operation was 56 years (42 to 79) and the mean period of follow-up was 7.2 years (5.0 to 13.0). The average Merle d’Aubigné and Postel score before operation was 10.3 and at final follow-up 15.0. There were excellent or good results in 42 hips (65%). Migration of the outer head was observed in 50 hips (77%), most often in the group with a centre-edge angle of less than 0°, an acetabular head index of less than 60%, coverage of the outer head by the original acetabulum of less than +10° and after bone grafting of the acetabulum. This migration was progressive in 31 (62%) of the 50 hips, with massive osteolysis of the acetabulum in eight. The extent and progression of migration were closely associated with this osteolysis. Four hips required revision for extensive migration of the outer head with destruction of the acetabulum or severe acetabular osteolysis, and nine hips are awaiting revision for failure of the bipolar prosthetic head. The overall failure rate was 18%. We report major problems after bipolar hip arthroplasty for osteoarthritis secondary to hip dysplasia with progressive migration of the outer head and massive acetabular osteolysis at five years or more after operation