Ulceration of the lower leg is considered to be a ‘hard’ clinical endpoint of venous thrombosis. Total knee replacement (TKR) is a significant risk factor for venous thrombosis of the leg and therefore potentially for ulceration.

We sent a postal questionnaire to 244 patients at a minimum of five years after TKR enquiring about the development of ulceration since their TKR. The overall incidence of ulceration, both active and healed, was 8.67% which is similar to that in the age-matched general population (9.6% to 12.6%), as was the prevalence of active ulceration. We also identified no clear association between venographically-confirmed postoperative deep-venous thrombosis (DVT) and the incidence and prevalence of ulcers at five years. We suggest that after TKR DVT is not a significant risk factor for ulceration of the leg and that perioperative chemical thromboprophylaxis may not be justified on these grounds.

The radiological features of the cement mantle around total hip replacements (THRs) have been used to assess aseptic loosening. In this case-control study we investigated the risk of failure of THR as predictable by a range of such features using data from patients recruited to the Trent Regional Arthroplasty Study (TRAS).

An independent radiological assessment was undertaken on Charnley THRs with aseptic loosening within five years of surgery and on a control group from the TRAS database. Chi-squared tests were used to test the probability of obtaining the observed data by chance, and odds ratios were calculated to estimate the strength of association for different features.

Several features were associated with a clinically important increase (> twofold) in the risk of loosening, which was statistically significant for four features (p < 0.01). Inadequate cementation (Barrack C and D grades) was the most significant feature, with an estimated odds ratio of 9.5 (95% confidence interval 3.2 to 28.4, p < 0.0001) for failure.

We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years.

The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years.

Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage.

We have assessed the usefulness of a regional hip register in the assessment of the outcome of primary total hip replacement (THR). Over 97% of THRs performed in the Trent region in 1990 were captured onto the register and the inaccuracies recorded were less than 1.8%. In an independent assessment of 2111 patients five years after THR, 85.9% of those available for assessment responded, and 66.8% agreed to an assessment.

The cost of this independent assessment at five years, utilising a regional hip register, was approximately £50 per implant. This is a reasonable outlay to identify problems early. Some form of registration and outcome assessment should be performed on a national level.

We recruited 89 patients who had hip or knee replacements to assess the performance of below-knee graded compression stockings. The pressure gradients generated by the stockings were measured and all patients had venography of the ipsilateral leg.

We found that 98% of stockings failed to produce the ‘ideal’ pressure gradient (± 20%) of 18, 14 and 8 mmHg from the ankle to the knee, while 54% produced a ‘reversed gradient’ on at least one occasion during the course of the study. The overall rate of deep-venous thrombosis was 16.7%. Stockings which produced reversed gradients were associated with a significantly higher incidence of deep-venous thrombosis (p = 0.026) than those with the correct gradient (25.6% v 6.1%). This suggests that the performance of graded compression stockings can be improved if reversed pressure gradients are detected and prevented.

Using a regional arthroplasty register we assessed the outcome at five years of 1198 primary Charnley total hip replacements (THRs) carried out in 1152 patients across a single UK health region in 1990. Information regarding outcome was available for 1080 hips (90%) and 499 had an independent clinical and radiological assessment.

By five years the known rate of aseptic loosening was 2.3%, of deep infection 1.4%, of dislocation 5.0% and of revision 3.2%. The radiological assessment of 499 THRs revealed gross failure in a further 5.2%, which had been previously unrecognised. The combined rate of failure of nearly 9% is higher than those published from specialist centres and surgeons, but is probably more representative of the norm.

Our study supports the need for a national register and surveillance of THRs. It emphasises that all implants should be followed, and suggests that the results of such surgery, when performed in the general setting, may not be as good as expected.

Radiological assessment of the cement mantle is used routinely to determine the outcome of total hip replacement. We performed a simulated replacement arthroplasty on cadaver femora and took standard postoperative radiographs. The femora were then sectioned into 7 mm slices starting at the calcar, and high-resolution faxitron radiographs were taken of these sections.

Analysis of the faxitron images showed that defects in the cement mantle were observed up to 100 times more frequently than on the standard films. We therefore encourage the search for a better technique in assessing the cement mantle.

As part of a prospective study of 476 total knee replacements (TKR), we evaluated the use of manipulation under anaesthesia in 47 knees. Manipulation was considered when intensive physiotherapy failed to increase flexion to more than 80°. The mean time from arthroplasty to manipulation was 11.3 weeks (median 9, range 2 to 41). The mean active flexion before manipulation was 62° (35 to 80). One year later the mean gain was 33° (Wilcoxon signed-rank test, range −5 to 70, 95% CI 28.5 to 38.5). Definite sustained gains in flexion were achieved even when manipulation was performed four or more months after arthroplasty (paired t-test, p < 0.01, CI 8.4 to 31.4).

A further 21 patients who met our criteria for manipulation declined the procedure. Despite continued physiotherapy, there was no significant increase in flexion in their knees. Six weeks to one year after TKR, the mean change was 3.1° (paired t-test, p = 0.23, CI −8.1 to +2).

Early implants for total knee replacement were fixed to bone with cement. No firm scientific reason has been given for the introduction of cementless knee replacement and the long-term survivorship of such implants has not shown any advantage over cemented forms. In a randomised, prospective study we have compared cemented and uncemented total knee replacement and report the results of 139 prostheses at five years. Outcome was assessed both clinically by independent examination using the Nottingham knee score and radiologically using the Knee Society scoring system.

Independent statistical analysis of the data showed no significant difference between cemented and cementless fixation for pain, mobility or movement. There was no difference in the radiological alignment at five years, but there was a notable disparity in the radiolucent line score. With cemented fixation there was a significantly greater number of radiolucent lines on anteroposterior radiographs of the tibia and lateral radiographs of the femur.

At five years, our clinical results would not support the use of the more expensive cementless fixation whereas the radiological results are of unknown significance. Longer follow-up will determine any changes in the results and conclusions.

A total of 110 total knee replacements (TKRs) was randomised to receive either a cemented or an uncemented prosthesis. Postoperative venography at five to seven days was used to compare the prevalence, site and size of deep-vein thrombosis (DVT). We also compared the findings with those of postoperative venography in a group of patients with cemented total hip replacements (THRs).

The total prevalence of DVT was significantly greater after uncemented (81%) than after cemented TKR (55%). Both knee groups had a significantly higher prevalence of DVT than in cemented hip replacements (32%). We found no difference in the proportion with proximal DVT in the three groups (14%, 15% and 16%). The median length of the thrombi was significantly greater after cemented (26.5 cm) than after uncemented TKR (11 cm) or after cemented THR (7 cm). This difference was mainly due to greater lengths of distal rather than proximal thrombi.

We conclude that the use of cement may affect the formation of DVT after joint replacement, but does not appear to lead to an increased incidence.

We calculated the rates for perioperative mortality and fatal pulmonary embolism (PE) after primary total hip replacement in a single UK health region, using a regional arthroplasty register and the tracing service of the Office of National Statistics. During 1990, there were 2111 consecutive primary replacements in 2090 separate procedures. Within 42 days of operation a total of 19 patients had died (0.91%, 95% CI 0.55 to 1.42). Postmortem examination showed that four deaths (0.19%, 95% CI 0.05 to 0.49) were definitely due to PE.

The overall perioperative mortality and fatal PE rates are low and in our study did not appear to be altered by the use of chemical thromboprophylaxis (perioperative mortality rate: one-tailed Fisher’s exact test, p = 0.39; fatal PE rate: one-tailed Fisher’s exact test, p = 0.56).

The routine use of chemical thromboprophylaxis for primary THR is still controversial. The issue should be addressed by an appropriate randomised, prospective study using overall mortality and fatal PE rate as the main outcome measures, but the feasibility of such a study is questioned.

We performed routine venography after operation in a consecutive series of 252 patients with total joint arthroplasties in whom no form of routine chemical or mechanical prophylaxis had been used.

The prevalence of deep-vein thrombosis (DVT) was 32% (16% distal, 16% proximal) after total hip replacement and 66% (50% distal, 16% proximal) after total knee replacement (p < 0.001). We did not treat distal DVT. There were only two readmissions within three months of surgery because of thromboembolic disease. There were two deaths within this period, neither of which was due to pulmonary embolism.

The newer techniques of cementing aim to improve interlock between cement and bone around a femoral stem by combining high pressure and reduced viscosity. This may produce increased embolisation of fat and marrow leading to hypotension, impaired pulmonary gas exchange and death. For this reason the use of high pressures has been questioned.

We compared finger-packing with the use of a cement gun by measuring intramedullary pressures during the cementing of 31 total hip replacements and measuring physiological changes in 19 patients. We also measured pressure in more detail in a laboratory model.

In the clinical series the higher pressures were produced by using a gun, but this caused less physiological disturbance than finger-packing. The laboratory studies showed more consistent results with the gun technique, but for both methods of cementing the highest pressures were generated during the insertion of the stem of the prosthesis.

We performed a prospective, randomised controlled trial in 177 patients who were having either total hip or knee replacement, to evaluate the use of both above- and below-knee graded compression stockings in the prevention of deep-vein thrombosis (DVT).

With above-knee stockings, we found no significant reduction of the overall, proximal or major calf (> 5 cm) DVT rates. With below-knee stockings, the overall thrombosis rate was similar to that of the control group but the stockings appeared to have altered the pattern of thrombosis. Patients who had total hip replacement and wore below-knee stockings had a significantly higher rate of proximal or major calf DVT (p = 0.03). This pattern was reversed in patients with total knee replacement who developed a significantly lower rate of proximal or major calf DVT with below-knee stockings (p < 0.05).

Our results showed that, with the exception of below-knee stockings in knee replacement patients, graded compression stockings were ineffective in preventing DVT after hip or knee replacement surgery.