Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:84–7.

Rarely, the extent of a malignant bone tumour may necessitate resection of the complete humerus to achieve adequate oncological clearance. We present our experience with reconstruction in such cases using a total humeral endoprosthesis (THER) in 20 patients (12 male and eight female) with a mean age of 22 years (6 to 59). We assessed the complications, the oncological and functional outcomes and implant survival. Surgery was performed between June 2001 and October 2009. The diagnosis included osteosarcoma in nine, Ewing’s sarcoma in eight and chondrosarcoma in three. One patient was lost to follow-up. The mean follow-up was 41 months (10 to 120) for all patients and 56 months (25 to 120) in survivors. There were five local recurrences (26.3%) and 11 patients were alive at time of last follow-up, with overall survival for all patients being 52% (95% confidence interval (CI) 23.8 to 74) at five years. The mean Musculoskeletal Tumor Society score for the survivors was 22 (73%; 16 to 23). The implant survival was 95% (95% CI 69.5 to 99.3) at five years.

The use of a THER in the treatment of malignant tumours of bone is oncologically safe; it gives consistent and predictable results with low rates of complication.

Discrepancy in leg length after total hip replacement has been associated with patient dissatisfaction. We prospectively studied 200 consecutive patients undergoing unilateral Charnley hip replacements to identify whether there is a demonstrable association between such disparity and postoperative function. Radiological measurements between defined points on the pelvis and femur of the operated hip were compared with the same points on the contralateral joint. A lengthening index was derived and statistical analysis used to compare this with validated functional outcome scores (Harris hip score and the SF36 Health Survey) and patient satisfaction.

Our results showed no statistical association between leg-length discrepancy after hip arthroplasty and functional outcome or patient satisfaction.

Direct anterior approaches to the hip have gained popularity as a minimally invasive method when performing primary total hip replacement (THR). A retrospective review of a single institution joint registry was performed in order to compare patient outcomes after THR using the Anterior Supine Intermuscular (ASI) approach versus a more conventional direct lateral approach. An electronic database identified 1511 patients treated with 1690 primary THRs between January 2006 and December 2010. Our results represent a summary of findings from our previously published work. We found that patients that underwent an ASI approach had faster functional recovery and higher Harris hip scores in the early post-operative period when compared with patients who had a direct lateral approach The overall complication rate in our ASI group was relatively low (1.7%) compared with other series using the same approach. The most frequent complication was early periprosthetic femoral fractures (0.9%). The dislocation rate in our series was 0.4% and the prosthetic joint infection rate was 0.1%. We suggest that the ASI approach is acceptable and safe when performing THR and encourages early functional recovery of our patients.

Cite this article: Bone Joint J 2014;96- B(11 Suppl A):32–5.

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).

We evaluated the duration of hospitalisation, occurrence of infections, hip dislocations, revisions, and mortality following primary hip and knee replacement in 857 patients with Parkinson’s disease and compared them with 2571 matched control patients. The data were collected from comprehensive nationwide Finnish health registers. The mean follow-up was six years (1 to 13). The patients with Parkinson’s disease had a longer mean length of stay (21 days [1 to 365] vs 13 [1 to 365] days) and an increased risk for hip dislocation during the first post-operative year (hazard ratio (HR) 2.33, 95% confidence intervals (CI) 1.02 to 5.32). There was no difference in infection and revision rates, and one-year mortality. In longer follow-up, patients with Parkinson’s disease had higher mortality (HR 1.94, 95% CI 1.68 to 2.25) and only 274 (34.7%) were surviving ten years after surgery. In patients with Parkinson’s disease, cardiovascular and psychiatric comorbidity were associated with prolonged hospitalisation and cardiovascular diseases also with increased mortality.

Cite this article: Bone Joint J 2014;96-B:486–91.

Radiostereometric analysis (RSA) can detect early micromovement in unstable implant designs which are likely subsequently to have a high failure rate. In 2010, the Articular Surface Replacement (ASR) was withdrawn because of a high failure rate. In 19 ASR femoral components, the mean micromovement over the first two years after implantation was 0.107 mm (sd 0.513) laterally, 0.055 mm (sd 0.204) distally and 0.150 mm (sd 0.413) anteriorly. The mean backward tilt around the x-axis was -0.08° (sd 1.088), mean internal rotation was 0.165° (sd 0.924) and mean varus tilt 0.238° (sd 0.420). The baseline to two-year varus tilt was statistically significant from zero movement, but there was no significant movement from one year onwards.

We conclude that the ASR femoral component achieves initial stability and that early migration is not the mode of failure for this resurfacing arthroplasty.

If patients could recall their physical status before total hip (THA) or knee arthroplasty (TKA) accurately it could have valuable applications both clinically and for research. This study evaluated the accuracy of a patient’s recollection one year after either THA or TKA using the Oxford hip or knee scores (OHS and OKS). In total, 113 patients (59 THA, 54 TKA) who had completed the appropriate score pre-operatively were asked to complete the score again at a mean of 12.4 months (standard deviation (sd) 0.8) after surgery, recalling their pre-operative state.

While there were no significant differences between the actual and recalled pre-operative scores (OHS mean difference 0.8, sd 6.21, 95% confidence interval (CI) -0.82 to 2.42, p = 0.329; OKS mean difference -0.11, sd 7.34, 95% CI -2.11 to 1.89, p = 0.912), absolute differences were relatively large (OHS, 5.24; OKS, 5.41), correlation was weak (OHS r = 0.7, OKS r = 0.61) and agreement between actual and recalled responses for individual questions was poor in half of the OHS and two thirds of the OKS.

A patient’s recollection of pre-operative pain and function is inaccurate one year after THA or TKA.

Cite this article: Bone Joint J 2015;97-B:1070–5.

The common recommended treatment for infected total hip replacement is two-staged exchange including removal of all components. However, removal of well-fixed femoral stems can result in structural bone damage. We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which a well-fixed femoral stem was left and only the acetabular component removed, the joint space was debrided thoroughly, an antibiotic-laden polymethylmethacrylate spacer was moulded using a bulb-type syringe and placed in the acetabulum, intravenous antibiotics were administered during the interval, and delayed re-implantation was performed. In 19 patients treated with this technique from January 2000 to January 2011, 89% were free of infection at a mean follow-up of four years (2 to 11). Since then, disposable silicone moulds have become available to fabricate spacers in separate femoral and head units. The head spacer mould, which incorporates various neck taper adapter options, greatly facilitates the technique of partial two-stage exchange. We report our early experience using disposable silicone head spacer moulds for partial two-stage exchange in seven patients with infected primary hip replacements.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):66–9

In developing countries locally-made low-cost prostheses are mainly used in limb-salvage surgery to alleviate the economic burden.

We retrospectively collected data on 104 patients treated by limb-salvage surgery between July 1997 and July 2005. We used a locally-designed and fabricated stainless-steel endoprosthesis in each case. Oncological and functional outcomes were evaluated at a mean follow-up of 47 months (12 to 118).

A total of 73 patients (70.2%) were free from disease, nine (8.7%) were alive with disease, 19 (18.2%) had died from their disease and three (2.9%) from unrelated causes. According to the Musculoskeletal Tumor Society scoring system, the mean functional score was 76.3% (SD 17.8). The five-year survival for the implant was 70.5%. There were nine cases (8.7%) of infection, seven early and two late, seven (6.7%) of breakage of the prosthesis, three (2.9%) of aseptic loosening and two (1.9%) of failure of the polyethylene bushing. Multivariate analysis showed that a proximal tibial prosthesis and a resection length of 14 cm or more were significant negative prognostic factors.

Our survival rates and Musculoskeletal Tumor Society functional scores are similar to those reported in the literature. Although longer follow-up is needed to confirm our results, we believe that a low-cost custom-made endoprosthesis is a cost-effective and reliable reconstructive option for limb salvage in developing countries.

We report serum metal ion level data in patients with unilateral and bilateral hip resurfacing over a ten-year period. In these patients there is an increase in both cobalt and chromium levels above the accepted reference ranges during the first 18 months after operation. Metal ion levels remain elevated, but decline slowly for up to five years. However, the levels then appear to start rising again in some patients up to the ten-year mark. There was no significant difference in cobalt or chromium levels between men and women. These findings appear to differ from much of the current literature.

The clinical significance of a raised metal ion level remains under investigation.

Total elbow replacement can be a valuable option for the treatment of the elbow in haemophilia where there are associated arthropathic changes. We describe the outcome of seven elbow replacements in five consecutive patients with severe haemophilia A (native factor levels < 1%) at a mean of 42 months (25 to 65) after operation. All the patients had excellent relief of pain and improvement in function. One failure was due to infection in an immunocompromised patient with both HIV and Hepatitis C antibodies who was on anti-retroviral chemotherapy. The implant was revised at 30 months in a one-stage procedure and showed no evidence of loosening or infection 35 months later.