We reviewed 44 consecutive revision hip replacements in 38 patients performed using the cement-in-cement technique. All were performed for acetabular loosening in the presence of a well-fixed femoral component. The mean follow-up was 5.1 years (2 to 10.1). Radiological analysis at final follow-up indicated no loosening of the femoral component, except for one case with a continuous radiolucent line in all zones and peri-prosthetic fracture which required further revision. Peri-operative complications included nine proximal femoral fractures (20.4%) and perforation of the proximal femur in one hip. In five hips wiring or fixation with a braided suture was undertaken but no additional augmentation was required. There was an improvement in the mean Japanese Orthopaedic Association score from 55.5 (28 to 81) pre-operatively to 77.8 (40 to 95) at final follow-up (p < 0.001). Revision using a cement-in-cement technique allows increased exposure for acetabular revision and is effective in the medium term. Further follow-up is required to assess the long-term results in the light of in vitro studies which have questioned the quality of the cement-in-cement bond.

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.

The use of volar locking compression plates for the treatment of fractures of the distal radius is becoming increasingly popular because of the stable biomechanical construct, less soft-tissue disturbance and early mobilisation of the wrist. A few studies have reported complications such as rupture of flexor tendons. We describe three cases of rupture of extensor tendons after the use of volar locking compression plates. We recommend extreme care when drilling and placing the distal radial screws to prevent damaging the extensor tendons.

Ultra-high-molecular-weight polyethylene sterilised in the absence of air and highly cross-linked polyethylene have been used to avoid osteolysis and loosening in total hip replacement. Our prospective randomised study has assessed the results using two different polyethylenes associated with the same prosthetic design. We assessed 45 Allofit acetabular components with a Sulene-polyethylene liner of conventional polyethylene gamma sterilised with nitrogen and 45 Allofit acetabular components with a Durasul-polyethylene liner sterilised in ethylene oxide, both matched with an Alloclassic stem with a 28 mm modular femoral head. The prostheses were implanted between May 1999 and December 2001. The mean follow-up was for 66.3 months (60 to 92). The linear penetration of the femoral head was estimated at 6 weeks, at 6 and 12 months and annually thereafter from standardised digitised radiographs using image-analysis software.

There was no loosening of any prosthetic component. There were no radiolucent lines or osteolysis. The mean rate of penetration calculated from regression analysis during the first five years was 38 μm/year (sd 2) for the Sulene group and 6 μm/year (sd 1) for the Durasul group (p = 0.00002). The rate of penetration of the Durasul group was 15.7% of that of the Sulene group.

The creep and wear behaviour of highly cross-linked polyethylene and standard polyethylene liners were examined in a prospective, double-blind randomised, controlled trial using radiostereometric analysis.

We randomised 54 patients to receive hip replacements with either highly cross-linked polyethylene or standard liners and determined the three-dimensional penetration of the liners over three years.

After three years the mean total penetration was 0.35 mm (SD 0.14) for the highly cross-linked polyethylene group and 0.45 mm (SD 0.19) for the standard group. The difference was statistically significant (p = 0.0184). From the pattern of penetration it was possible to discriminate creep from wear. Most (95%) of the creep occurred within six months of implantation and nearly all within the first year. There was no difference in the mean degree of creep between the two types of polyethylene (highly cross-linked polyethylene 0.26 mm, SD 0.17; standard 0.27 mm, SD 0.2; p = 0.83). There was, however, a significant difference (p = 0.012) in the mean wear rate (highly cross-linked polyethylene 0.03 mm/yr, SD 0.06; standard 0.07 mm/yr, SD 0.05). Creep and wear occurred in significantly different directions (p = 0.01); creep was predominantly proximal whereas wear was anterior, proximal and medial.

We conclude that penetration in the first six months is creep-dominated, but after one year virtually all penetration is due to wear. Highly cross-linked polyethylene has a 60% lower rate of wear than standard polyethylene and therefore will probably perform better in the long term.

A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes.

The patients were categorised into three groups: non-obese (body mass index (BMI) < 30 kg/m²), obese (BMI 30 to 40 kg/m²) and morbidly obese (BMI > 40 kg/m²). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%)

There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients.

Surgical access to the head of the radius is usually performed through a lateral approach. We present an alternative technique through a modified posterior approach which was developed following dissections of 22 human cadavers. An osteotomy of the supinator tuberosity was performed and reflected as a single unit with the attached annular ligament. Excellent exposure of the head of the radius was achieved, replacement of the head was undertaken and the osteotomy site repaired. The elbows were stable and had a full range of movement. The approach was then carried out on 13 patients for elective replacement of the head and was found to be safe and reproducible. In the patient group all osteotomies united, the elbows were stable and had an improved range of supination and pronation. There was no change in flexion and extension of the elbow. Complications included a haematoma and a reflex sympathetic dystrophy.

The modified posterior approach provides excellent access to the head and neck of the radius, gives good stability of the elbow and allows early mobilisation of the joint.

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5° of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (< 5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001).

We have evaluated the effect of vacuum aspiration of the iliac wing on the osseointegration of cement into the acetabulum. We entered a total of 40 patients undergoing primary total hip arthroplasty into two consecutive study groups. Group 1 underwent acetabular cement pressurisation for 60 seconds before insertion of the acetabular component. Group 2 had the same pressurisation with simultaneous vacuum suction of the ilium using an iliac-wing aspirator. Standard post-operative radiographs were reviewed blindly to assess the penetration of cement into the iliac wing. Penetration was significantly greater in the group with aspiration of the iliac wing.

The aim of this study was to compare the results in patients having a quadriceps sparing total knee replacement (TKR) with those undergoing a standard TKR at a minimum follow-up of two years.

All patients who had a TKR with a high-flex posterior-stabilised prosthesis prior to December 2002 were reviewed retrospectively. There were 57 patients available for follow-up. Those with a quadriceps sparing TKR had less pain peri-operatively with a greater degree of flexion at all the post-operative visits and at the final follow-up, but their operations took longer, with less accurate radiological alignment. There was no difference in the complications and in the Knee Society scores between the two groups at the final follow-up.

Total knee replacement through a quadriceps sparing approach has some peri-operative advantages over the standard incision. At a minimum follow-up of two years the clinical results were similar to those with a standard incision, but the radiological outcomes of the quadriceps sparing group were inferior.

The results of 41 consecutive total knee replacements performed on morbidly obese patients with a body mass index > 40 kg/m², were compared with a matched group of 41 similar procedures carried out in non-obese patients (body mass index < 30 kg/m²). The groups were matched for age, gender, diagnosis, type of prosthesis, laterality and pre-operative Knee Society Score. We prospectively followed up the patients for a mean of 38.5 months (6 to 66). No patients were lost to follow-up. At less than four years after operation, the results were worse in the morbidly obese group compared with the non-obese, as demonstrated by inferior Knee Society Scores (mean knee score 85.7 and 90.5 respectively, p = 0.08; mean function score 75.6 and 83.4, p = 0.01), a higher incidence of radiolucent lines on post-operative radiographs (29% and 7%, respectively, p = 0.02), a higher rate of complications (32% and 0%, respectively, p = 0.001) and inferior survivorship using revision and pain as end-points (72.3% and 97.6%, respectively, p = 0.02).

Patients with a body mass index > 40 kg/m² should be advised to lose weight prior to total knee replacement and to maintain weight reduction. They should also be counselled regarding the inferior results which may occur if they do not lose weight before surgery.

We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency.

Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4° and mean abduction improved by 35°. There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications.

The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss.

We report an independent prospective review of the first 230 Birmingham hip resurfacings in 212 patients at a mean follow-up of five years (4 to 6).

Two patients, one with a loose acetabular component and the other with suspected avascular necrosis of the femoral head, underwent revision. There were two deaths from unrelated causes and one patient was lost to follow-up. The survivorship with the worst-case scenario was 97.8% (95% confidence interval 95.8 to 99.5). The mean Harris hip score improved significantly (paired t-test, p < 0.05) from 62.54 (8 to 92) pre-operatively to 97.7 (61 to 100) at a mean of three years (2.1 to 4.3), then deteriorated slightly to a mean of 95.2 (47 to 100) at a mean of five years. The mean flexion improved from 91.5° (25° to 140°) to 110.4° (80° to 145°) at a mean of three years with no further improvement at five years (111.2°; 70° to 160°).

On radiological review at five years, one patient had a progressive lucent line around the acetabular component and six had progressive lucent lines around the femoral component. A total of 18 femoral components (8%) had migrated into varus and those with lucent lines present migrated a mean of 3.8° (1.02° to 6.54°) more than the rest. Superolateral notching of the femoral neck and reactive sclerosis at the tip of the peg of the femoral component were associated with the presence of lucent lines (chi-squared test, p < 0.05), but not with migration of the femoral component, and are of unknown significance.

Our results with the Birmingham hip resurfacing continue to be satisfactory at a mean follow-up of five years.

The Morscher-Spotorno (MS-30) femoral stem is a stainless-steel, straight, three-dimensionally tapered, collarless implant for cemented fixation in total hip replacement.

We report the results at ten years of a consecutive series of 124 total hip replacements in 121 patients with the matt-surfaced MS-30 stem and an alumina ceramic head of 28-mm diameter. All the stems were fixed with Palacos bone cement with gentamicin using a modern cementing technique. They were combined with an uncemented, press-fit cup. The mean period of observation was 10.2 years (8.3 to 12.1) and no patient was lost to follow-up. Twenty-seven patients (22%) died with the implant in situ. Nine could only be interviewed by telephone. We included 85 patients with 88 hips in the clinical and radiological follow-up examinations.

None of the stems or cups had been revised. The Harris hip score was excellent or good in 97% (85 hips) and moderate in 3% (three hips). Radiologically, six hips (6.8%) had osteolysis adjacent to the stem, mostly in Gruen zone 7. Twenty (22.7%) showed one or more radiolucent lines. Twenty-two stems (25%) had subsided by 2 mm to 5 mm. In these cases two showed osteolysis (9.1%) with subsidence and four without (6.1%). Radiolucent lines were seen in seven with migration (31.8%) and in 13 without (19.7%). No infections and no acetabular osteolysis were observed.

The clinical results were excellent with survivorship after ten years of 100% and only a slightly statistically non-significant higher rate of osteolysis and radiolucency in cases of subsidence.

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure.

Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months.

Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion.

Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

We present a retrospective series of 170 cemented titanium straight-stem femoral components combined with two types of femoral head: cobalt-chromium (CoCr) alloy (114 heads) and alumina ceramic (50 heads). Of the study group, 55 patients (55 stems) had died and six (six stems) were lost to follow-up. At a mean of 13.1 years (3 to 15.3) 26 stems had been revised for aseptic loosening. The mean follow-up time for stable stems was 15.1 years (12.1 to 16.6).

Survival of the stem at 15 years was 75.4% (95% confidence interval (CI) 67.3 to 83.5) with aseptic failure (including radiological failure) as the end-point, irrespective of the nature of the head and the quality of the cement mantle. Survival of the stem at 15 years was 79.1% (95% CI 69.8 to 88.4) and 67.1% (95% CI 51.3 to 82.9) with the CoCr alloy and ceramic heads, respectively. The quality of the cement mantle was graded as a function of stem coverage: stems with complete tip coverage (type 1) had an 84.9% (95% CI 77.6 to 92.2) survival at 15 years, compared with those with a poor tip coverage (type 2) which had a survival of only 22.4% (95% CI 2.4 to 42.4). The poor quality of the cement mantle and the implantation of an alumina head substantially lowered the survival of the stem.

In our opinion, further use of the cemented titanium alloy straight-stem femoral components used in our series is undesirable.

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.

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery.

Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

Between January 1998 and December 1998, 82 consecutive patients (86 hips) underwent total hip arthroplasty using a trabecular metal monoblock acetabular component. All patients had a clinical and radiological follow-up evaluation at six, 12 and 24 weeks, 12 months, and then annually thereafter. On the initial post-operative radiograph 25 hips had a gap between the outer surface of the component and the acetabular host bed which ranged from 1 to 5 mm. All patients were followed up clinically and radiologically for a mean of 7.3 years (7 to 7.5). The 25 hips with the 1 to 5 mm gaps were studied for component migration at two years using the Einzel-Bild-Roentgen-Analyse (EBRA) digital measurement method. At 24 weeks all the post-operative gaps were filled with bone and no acetabular component had migrated. The radiographic outcome of all 86 components showed no radiolucent lines and no evidence of lysis. No acetabular implant was revised. There were no dislocations or other complications. The bridging of the interface gaps (up to 5 mm) by the trabecular metal monoblock acetabular component indicates the strong osteoconductive, and possibly osteoinductive, properties of trabecular metal.

There are theoretical and practical advantages to modular rather than monoblock designs of prostheses for shoulder arthroplasty, but there are no reported studies which specifically compare the clinical and radiological results of their use. We have compared the results of unconstrained total shoulder arthroplasty for osteoarthritis using both types of implant. The monoblock design was used between 1992 and 1995 and the modular design after 1995. Both had cemented all-polyethylene glenoids, the monoblock with matched and the modular with mismatched radii of curvature. There were 34 consecutive shoulders in each group with a mean follow-up of 6.1 years in the first and 5.2 years in the second.

There were no significant differences in improvement of pain scores, active elevation, external rotation, internal rotation, patient satisfaction, or the Neer ratings between the two groups. Two of 28 glenoid components in the first group and six of 30 in the second met the criteria for being radiologically at risk for loosening (p = 0.25). There were no significant differences in clinical outcome or radiological changes between the first- and second-generation designs of implant for shoulder arthroplasty.