We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01).

Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.

We present a prospective review of the two-year functional outcome of 37 Avon patellofemoral joint replacements carried out in 29 patients with a mean age of 66 years (30 to 82) between October 2002 and March 2007. No patients were lost to follow-up. This is the first independent assessment of this prosthesis using both subjective and objective analysis of outcome. At two years the median Oxford knee score was 39 (interquartile range 32 to 44), the median American Knee Society objective score was 95 (interquartile range 90 to 100), the median American Knee Society functional score was 85 (interquartile range 60 to 100), and the median Melbourne Knee score was 28 (interquartile range 21 to 30). Two patients underwent further surgery. Only one patient reported an unsatisfactory outcome.

We conclude that the promising early results observed by the designing centre are reproducible and provide further support for the role of patellofemoral joint replacement.

We studied a consecutive series of 285 uncemented total hip replacements in 260 patients using the Taperloc femoral component and the T-Tap acetabular component. The outcome of every hip was determined in both living and deceased patients. A complete clinical and radiological follow-up was obtained for 209 hips in 188 living patients, followed for a mean of 14.5 years (10 to 18.9). They were divided into two groups, obese and non-obese, as determined by their body mass index. There were 100 total hip replacements in 89 patients in the obese cohort (body mass index ≥ 30 kg/m²), and 109 in 99 non-obese (body mass index < 30 kg/m²) patients. A subgroup analysis of 31 patients of normal weight (body mass index 20 kg/m² to 25 kg/m²) (33 hips) and 26 morbidly obese patients (body mass index ≥ 35 kg/m²) (30 hips) was also carried out.

In the obese group five femoral components (5%) were revised and one (1%) was loose by radiological criteria. Femoral cortical osteolysis was seen in eight hips (8%). The acetabular component was revised in 57 hips (57%) and a further 17 (17%) were loose. The mean Harris hip score improved from 52 (30 to 66) pre-operatively to 89 (49 to 100) at final follow-up. Peri-operative complications occurred in seven patients (7%).

In the non-obese group six (6%) femoral components were revised and one (1%) was loose. Femoral cortical osteolysis occurred in six hips (6%). The acetabular component was revised in 72 hips (66%) and a further 18 (17%) were loose. The mean Harris hip score increased from 53 (25 to 73) prior to surgery to 89 (53 to 100) at the time of each patient’s final follow-up radiograph.

No statistically significant difference was identified between the obese and non-obese patients with regards to clinical and radiological outcome or complications. The subgroup analysis of patients of normal weight and those who were morbidly obese showed no statistically significant difference in the rate of revision of either component.

Our findings suggest there is no evidence to support withholding total hip replacement from obese patients with arthritic hips on the grounds that their outcome will be less satisfactory than those who are not obese.

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction.

Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant.

The outcome of total hip replacement (THR) is potentially affected by the body mass index (BMI) of the patient. We studied the outcome of 2026 consecutive primary cementless THRs performed for osteoarthritis. The mean follow-up was 6.3 years (0 to 11.71) and no patient was lost to follow-up for survival analysis. The patients were divided into two groups according to their BMI as follows: non-obese (BMI < 30 kg/m²) and obese (BMI ≥ 30 kg/m²).

The obese patient undergoing surgery was found to be significantly younger (p < 0.001). The log-rank test for equality of survival showed no difference in the mid-term survival (p = 0.552) with an estimated survival at 11 years of 95.2% (95% CI 92.5 to 98.0) in the non-obese and 96.7% (95% CI 94.9 to 98.5) in the obese groups. The clinical and radiological outcome was determined in a case-matched study performed on 134 obese individuals closely matched with 134 non-obese controls. The non-obese group was found to have a significantly higher post-operative Harris hip score (p < 0.001) and an increased range of movement, but overall satisfaction with surgery was comparable with that of the obese patients. Radiological analysis of the acetabular and femoral components showed no significant differences with regard to radiolucent lines, osteolysis, ingrowth of the femoral component, the acetabular inclination angle or alignment of the femoral component. Our results suggest that the survival of cementless THR is not adversely affected by obesity. Obese patients can therefore be counselled that despite a lower clinical score, they should expect to be satisfied with the result of their THR with a mid-term survival rate equivalent to that of non-obese patients.

We have evaluated the in vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements which were undertaken in 155 patients. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem before line-to-line cementing. We used the Ein Bild Roentgen Analyse femoral component method to assess the subsidence of the femoral component.

At a mean of 17.3 years (15.1 to 18.3) 73 patients were still alive and had not been revised, eight had been revised, 66 had died and eight had been lost to follow-up. The mean subsidence of the entire series was 0.63 mm (0.0 to 1.94). When using a 1.5 mm threshold, only four stems were considered to have subsided. Our study showed that, in most cases, a highly polished double-tapered stem cemented line-to-line does not subside at least up to 18 years after implantation.

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours.

On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.

Replacement of the shoulder in juvenile idiopathic arthritis is not often performed and there have been no published series to date.

We present nine glenohumeral hemiarthroplasties in eight patients with systemic or polyarticular juvenile idiopathic arthritis. The mean follow-up was six years (59 to 89 months). The mean age at the time of surgery was 32 years. Surgery took place at a mean of 27 years after diagnosis. The results indicated excellent relief from pain. There was restoration of useful function which deteriorated with time, in part because of progression of the systemic disease in this severely affected group. No patient has required revision to date and there has been no radiological evidence of loosening or osteolysis around the implants.

We discuss the pathoanatomical challenges unique to this group. There was very little space for a prosthetic joint and, in some cases, bony deformity and the small size necessitated the use of custom-made implants.

Narrow, well-defined radiolucent lines commonly observed at the bone-implant interface of unicompartmental knee replacement tibial components have been referred to as physiological radiolucencies. These should be distinguished from pathological radiolucencies, which are poorly defined, wide and progressive, and associated with loosening and infection. We studied the incidence and clinical significance of tibial radiolucent lines in 161 Oxford unicondylar knee replacements five years after surgery. All the radiographs were aligned with fluoroscopic control to obtain views parallel to the tibial tray to reveal the tibial bone-implant interface.

We found that 49 knees (30%) had complete, 52 (32%) had partial and 60 (37%) had no radiolucent lines. There was no relationship between the incidence of radiolucent lines and patient factors such as gender, body mass index and activity, or operative factors including the status of the anterior cruciate ligament and residual varus deformity. Nor was any statistical relationship established between the presence of radiolucent lines and clinical outcome, particularly pain, assessed by the Oxford Knee score and the American Knee Society score.

We conclude that radiolucent lines are common after Oxford unicompartmental knee replacement but that their aetiology remains unclear. Radiolucent lines were not a source of adverse symptoms or pain. Therefore, when attempting to identify a source of postoperative pain after Oxford unicompartmental knee replacement the presence of a physiological radiolucency should be ignored.

As part of the government’s initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement. The Kinemax total knee replacement system was used in all cases. The cumulative survival rate at three years was 79.2% (95% confidence interval (CI) 69.2 to 86.8) using re-operation for any cause as an endpoint and 85.3% (95% CI 75.9 to 91.8) using aseptic revision as an endpoint. This is significantly worse than that recorded in the published literature. These poor results have resulted in a significant impact on our service.

We performed two independent, randomised, controlled trials in order to assess the potential benefits of immediate weight-bearing mobilisation after rupture of the tendo Achillis. The first trial, on operatively-treated patients showed an improved functional outcome for patients mobilised fully weight-bearing after surgical repair. Two cases of re-rupture in the treatment group suggested that careful patient selection is required as patients need to follow a structured rehabilitation regimen. The second trial, on conservatively-treated patients, provided no evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular, there was no evidence of tendon lengthening or a higher re-rupture rate. We would advocate immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the tendo Achillis.

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty.

In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105 712 cases.

We describe the survivorship of the Exeter femoral component in a District General Hospital. Between 1994 and 1996, 230 Exeter Universal cemented femoral components were implanted in 215 patients who were reviewed at a mean of 11.2 years (10 to 13). We used one acetabular implant, the Elite Ogee component, in 218 of the 230 hips.

During the period of this study 76 patients (79 hips) died. Of the remaining 139 patients (151 hips), 121 were able to attend for radiological analysis at a minimum of ten years. One patient was lost to follow-up.

No femoral component was revised for aseptic loosening. Three hips were revised for deep infection and six acetabular components required revision, four for loosening and two for recurrent dislocation. Taking the ‘worst-case scenario’ including the one patient lost to follow-up, the overall survival rate was 94.4% at 13 years.

Our results confirm excellent medium-term results for the Exeter Universal femoral component, implanted in a general setting. The excellent survival of this femoral component, when used in combination with the Ogee acetabular component, suggests that this is a successful pairing.

There have been no large comparative studies of the blood levels of metal ions after implantation of commercially available hip resurfacing devices which have taken into account the effects of femoral size and inclination and anteversion of the acetabular component. We present the results in 90 patients with unilateral articular surface replacement (ASR) hip resurfacings (mean time to blood sampling 26 months) and 70 patients with unilateral Birmingham Hip Resurfacing (BHR) implants (mean time 47 months).

The whole blood and serum chromium (Cr) and cobalt (Co) concentrations were inversely related to the size of the femoral component in both groups (p < 0.05). Cr and Co were more strongly influenced by the position of the acetabular component in the case of the ASR, with an increase in metal ions observed at inclinations > 45° and anteversion angles of < 10° and > 20°. These levels were only increased in the BHR group when the acetabular component was implanted with an inclination > 55°.

A significant relationship was identified between the anteversion of the BHR acetabular component and the levels of Cr and Co (p < 0.05 for Co), with an increase observed at anteversion angles < 10° and > 20°. The median whole blood and serum Cr concentrations of the male ASR patients were significantly lower than those of the BHR men (p < 0.001). This indicates that reduced diametral clearance may equate to a reduction in metal ion concentrations in larger joints with satisfactory orientation of the acetabular component.

The outcome of displaced hips treated by Somerville and Scott’s method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change.

The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

We have reviewed 70 Harris-Galante uncemented acetabular components implanted as hybrid hip replacements with cemented stems between 1991 and 1995 in 53 patients whose mean age was 40 years (19 to 49). The mean follow-up was for 13.6 years (12 to 16) with no loss to follow-up. We assessed the patients both clinically and radiologically.

The mean Oxford hip score was 20 (12 to 46) and the mean Harris hip score 81 (37 to 100) at the final review. Radiologically, 27 hips (39%) had femoral osteolysis, 13 (19%) acetabular osteolysis, and 31 (44%) radiolucent lines around the acetabular component. Kaplan-Meier survival curves were constructed for the outcomes of revision of the acetabular component, revision of the component and polyethylene liner, and impending revision for progressive osteolysis.

The cumulative survival for revision of the acetabular component was 94% (95% confidence interval 88.4 to 99.7), for the component and liner 84% (95% confidence interval 74.5 to 93.5) and for impending revision 55.3% (95% confidence interval 40.6 to 70) at 16 years.

Uncemented acetabular components with polyethylene liners undergo silent lysis and merit regular long-term radiological review.

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998.

The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification.

The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively.

Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97).

The Unispacer knee system is a cobalt-chrome self-centring tibial hemiarthroplasty device for use in the treatment of isolated medial compartment osteoarthritis of the knee. The indications for use are similar to those for high tibial osteotomy, but insertion does not require bone cuts or component fixation, and does not compromise future knee replacement surgery. A prospective study of a consecutive series of 18 patients treated with the Unispacer between June 2003 and August 2004 was carried out to determine the early clinical results of this device. The mean age of the patients was 49 years (40 to 57). A total of eight patients (44%) required revision within two years. In two patients revision to a larger spacer was required, and in six conversion to either a unicompartmental or total knee replacement was needed. At the most recent review 12 patients (66.7%) had a Unispacer remaining in situ. The mean modified visual analogue score for these patients at a mean follow-up of 19 months (12 to 26) was 3.0 (0 to 11.5). The mean pain level was 30% that of the mean pre-operative level of 10. The early clinical results using this device have been disappointing.

This study demonstrates that use of the Unispacer in isolated medial compartment osteoarthritis is associated with a high rate of revision surgery and provides unpredictable relief of pain.

We carried out a prospective study to assess the clinical outcome, complications and survival of the NexGen Legacy posterior-stabilised-Flex total knee replacement (TKR) in a consecutive series of 278 knees between May 2003 and February 2005. Mean follow-up for 259 TKRs (98.2%) was 3.8 years (3.0 to 4.8). Annual follow-up showed improvement in the Knee Society scores (paired t-test, p < 0.05). At the last follow-up, the mean maximum flexion was 135° (110° to 150°). Two knees showed radiolucent lines, but revision was not required because the patients were asymptomatic. Revision was required in one case because of infection, but there were no prosthesis-related revisions. There were no other complications. The estimated survival rate at four years with revision for any reason and prosthesis-related problems was 99.6% and 100%, respectively.

This relatively large study indicates that the legacy posterior stabilised-Flex design provides excellent short-term outcome but warrants ongoing evaluation to confirm the long-term durability and functioning of the implant.