The early designs of hip resurfacing implants suffered high rates of early failure, making it impossible to obtain valuable mid-term radiostereophotogrammetric (RSA) results. The metal-on-metal Birmingham Hip Resurfacing arthroplasty has shown promising mid-term results and we present here the first mid-term RSA analysis of a hip resurfacing implant.

The analysis was performed in 19 hips at five years post-operatively. The mean acetabular component translation and rotation, and femoral component translation were compared with the previous RSA measurements at two and six months, and one and two years.

There was no statistical significance (t-test, p ≤ 0.05) between these consecutive movements, indicating the mid-term stability of the implant.

Few independent studies have reported the outcome of resurfacing arthroplasty of the hip. The aim of this study was to report the five-year clinical outcome and seven-year survival of an independent series.

A total of 610 Birmingham Hip Resurfacing arthroplasties were performed in 532 patients with a mean age of 51.8 years (16.5 to 81.6). They were followed for between two and eight years; 107 patients (120 hips) had been followed up for more than five years. Two patients were lost to follow-up. At a minimum of five years’ follow-up, 79 of 85 hips (93%) had an excellent or good outcome according to the Harris hip score. The mean Oxford hip score was 16.1 points (sd 7.7) and the mean University of California Los Angeles activity score was 6.6 points (sd 1.9). There were no patients with definite radiological evidence of loosening or of narrowing of the femoral neck exceeding 10% of its width. There were 23 revisions (3.8%), giving an overall survival of 95% (95% confidence interval 85.3 to 99.2) at seven years. Fractured neck of femur in 12 hips was the most common indication for revision, followed by aseptic loosening in four. In three hips (three patients) (0.5%), failure was possibly related to metal debris.

Considering that these patients are young and active these results are good, and support the use of resurfacing. Further study is needed to address the early failures, particularly those related to fracture and metal debris.

Transient osteoporosis of the hip is a disorder characterised by pain, and associated with temporary osteopaenia. Although osteopaenia is the essence of the condition, data do not exist about the local bone density of the femoral neck if no medication is administered. We describe three patients who were treated with limitation of weight-bearing only. Repeated bone mineral density measurements were obtained, and that at the femoral neck was lowest two months after the onset of the condition. The mean reduction in bone mineral density when compared with an age-matched control group was 13% (3% to 24%). Spontaneous recovery was observed in all patients.

For over a decade, bisphosphonate administration has evolved and become the cornerstone of the prevention and treatment of fragility fractures. Millions of post-menopausal women have relied on, and continue to depend on, the long-acting, bone density-maintaining pharmaceutical drug to prevent low-energy fractures. In return, we have seen the number of fragility fractures decrease, along with associated costs and emotional benefits. However, with any drug, there are often concerns with side effects and complications, and this unique drug class is seeing one such complication in atypical subtrochanteric femoral fracture, counterproductive to that which it was designed to prevent. This has created concern over long-term bisphosphonate administration and its potential link to these atypical fractures. There is controversial evidence surrounding such a definitive link, and no protocol for managing these fractures.

This review offers the latest information regarding this rare but increasingly controversial adverse effect and its potential connection to one of the most successful forms of treatment that is available for the management of fragility fractures.

We reviewed the initial post-operative radiographs of the Trident acetabulum and identified a problem with seating of the metal-backed ceramic liner. We identified 117 hips in 113 patients who had undergone primary total hip replacement using the Trident shell with a metal-backed alumina liner. Of these, 19 (16.4%) were noted to have incomplete seating of the liner, as judged by plain anteroposterior and lateral radiographs. One case of complete liner dissociation necessitating early revision was not included in the prevalence figures. One mis-seated liner was revised in the early post-operative period and two that were initially incompletely seated were found on follow-up radiographs to have become correctly seated. There may be technical issues with regard to the implanting of this prosthesis of which surgeons should be aware. However, there is the distinct possibility that the Trident shell deforms upon implantation, thereby preventing complete seating of the liner.

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 describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

Resurfacing arthroplasty of the hip is being performed more frequently in the United Kingdom. The majority of these patients are younger than 55 years of age, and in this group the key benefits include conservation of femoral bone stock and the potential reduction in the rate of dislocation afforded by the larger resurfacing head. Early aseptic loosening is well recognised in patients younger than 55 years of age, and proponents of resurfacing believe that the improved wear characteristics of the metal-on-metal bearing may improve the long-term survival of this implant. There has been some concern, however, that resurfacing may not be conservative of acetabular bone.

We compared a series of 33 consecutive patients who had a hybrid total hip arthroplasty with an uncemented acetabular component and a cemented femoral implant, with 35 patients undergoing a Birmingham hip resurfacing arthroplasty. We compared the diameter of the implanted acetabulum in both groups and, because they were not directly comparable, we corrected for patient size by measuring the diameter of the contralateral femoral head. The data were analysed using unpaired t-tests and analysis of covariance.

There was a significantly larger acetabulum in the Birmingham arthroplasty group (mean diameter 56.6 mm vs 52.0 mm; p < 0.001). However, this group had a significantly larger femoral head diameter on the contralateral side (p = 0.03). Analysis of covariance revealed a significant difference between the mean size of the acetabular component implanted in the two operations. The greatest difference in the size of acetabulum was in those patients with a larger diameter of the femoral head. This study shows that more bone is removed from the acetabulum in hip resurfacing than during hybrid total hip arthroplasty, a difference which is most marked in larger patients.

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery.

In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA.

No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs.

MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.

The incidence and long-term outcome of undisplaced fatigue fractures of the femoral neck treated conservatively were examined in Finnish military conscripts between 1970 and 1990.

From 106 cases identified, 66 patients with 70 fractures were followed for a mean of 18.3 years (11 to 32). The original medical records and radiographs were studied and physical and radiological follow-up data analysed for evidence of risk factors for this injury. The development of avascular necrosis and osteoarthritis was determined from the follow-up radiographs and MR scans.

The impact of new military instructions on the management of hip-related pain was assessed following their introduction in 1986. The preventive regimen (1986) improved awareness and increased the detected incidence from 13.2 per 100 000 service-years (1970 to 1986) to 53.2 per 100 000 (1987 to 1990). No patient developed displacement of the fracture or avascular necrosis of the femoral head, or suffered from adverse complications. No differences were found in MRI-measured hip joint spaces at final follow-up. The mean Harris Hip Score was 97 (70 to 100) and the Visual Analogue Scale 5.85 mm (0 to 44).

Non-operative treatment, including avoidance of or reduced weight-bearing, gave favourable short- and long-term outcomes. Undisplaced fatigue fractures of the femoral neck neither predispose to avascular necrosis nor the subsequent development of osteoarthritis of the hip.

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.

The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001.

There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents.

Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study.

These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital.

We present the medium-term results of hybrid total hip arthroplasties using pre-coated stems with a second-generation cementing technique. The 128 hips in 111 patients (18 men and 93 women) were followed up at a mean of 11 years after surgery. The mean age at the time of surgery was 61 years. Both components of one hip were removed at ten months after surgery for infection. None of the other 127 femoral components showed possible, probable, or definite loosening at the most recent follow-up. Five acetabular components were revised for aseptic loosening, recurrent dislocation, or displacement of the polyethylene liner from the metal shell. The mean Harris hip score at follow-up was 84 points. A pre-coated femoral component with a second-generation cementing technique provides good clinical function and survival in the medium term.

We present the histological findings of bone retrieved from beneath the femoral components of failed metal-on-metal hip resurfacing arthroplasties. Of a total of 377 patients who underwent resurfacing arthroplasty, 13 required revision; for fracture of the femoral neck in eight, loosening of a component in three and for other reasons in two. None of these cases had shown histological evidence of osteonecrosis in the femoral bone at the time of the initial implantation.

Bone from the remnant of the femoral head showed changes of osteonecrosis in all but one case at revision. In two cases of fracture which occurred within a week of implantation, the changes were compatible with early necrosis of the edge of the fracture. In the remaining six fractures, there were changes of established osteonecrosis. In all but one of the non-fracture cases, patchy osteonecrosis was seen.

We conclude that histological evidence of osteonecrosis is a common finding in failed resurfaced hips. Given that osteonecrosis is extensive in resurfaced femoral heads which fail by fracture, it is likely to play a role in the causation of these fractures.

We describe the experience with the first consecutive 230 Birmingham hip resurfacings at our centre. At a mean follow-up of three years (25 to 52 months) survivorship was 99.14% with revision in one patient for a loose acetabular component and one death from unrelated causes. One patient developed a fracture of the femoral neck at six weeks which united unremarkably after a period of non-weight-bearing. The Harris hip score improved from a mean of 62.54 (8 to 92) to 97.74 (61 to 100). The mean flexion improved from 91.52° (25 to 140) to 110.41° (80 to 145).

Most patients (97%) considered the outcome to be good or excellent. Our preliminary experience with this implant is encouraging and the results are superior to the earlier generation of resurfacings for the same length of follow-up.

This study assessed whether undergraduate performance improved following the introduction in 2006 of a musculoskeletal teaching programme lasting for seven weeks. Different methods were used to deliver knowledge and skills in trauma and orthopaedic surgery, rheumatology and allied specialties. The programme combined four main elements: traditional firm-based teaching, weekly plenary sessions, a task-based workbook and additional specialist clinics. The block of 139 students who attended in its first year were assessed using a multiple choice question examination just before their final examinations in 2008. They showed a 6% improvement in performance over a control group of 130 students assessed in 2005 before the programme had commenced. There was no difference in performance between the students assessed in 2005 and a second group of 46 students from 2008 who did not attend the new teaching programme. Performance was improved by providing more focused musculoskeletal training using available resources, as well as increasing the length of the programme.

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors.

Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40).

Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications.

We have evaluated retrospectively the relationship of bony injuries seen on 106 consecutive MR scans in elderly patients of a mean age of 81.4 years (67 to 101) who were unable to bear weight after a low-energy injury.

There were no visible fractures on plain radiographs of the hip but eight patients (7.5%) had fractures of the pubic ramus. In 43 patients (40.5%) MRI revealed a fracture of the femoral neck and in 26 (24.5%) there was a fracture of a pubic ramus. In 17 patients (16%) MRI showed an occult sacral fracture and all of these had a fracture of the pubic ramus. No patient with a fracture of the femoral neck had an associated fracture of the pelvic ring or vice versa. Occult fracture of the hip and of the pelvic ring appear to be mutually exclusive and if an acute fracture of the pubic ramus is diagnosed radiologically further investigations are not needed to rule out an occult fracture of the hip.

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound.

Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.