We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 (sd 14) of a possible 100 points. Regular participation in moderate to strenuous activities was possible for only seven patients pre-operatively; this increased to 23 patients post-operatively. The mean Lysholm score improved from 64 (sd 15) to 90 (sd 14) at ten years (p = 0.001).

At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament.

This procedure for symptomatic patients with posterior cruciate ligament laxity who have failed conservative management offers good results.

This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult.

The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70).

No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results.

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.

We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal ‘tube’ realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score.

There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the ‘four-in-one’ procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.

A cadaver study using six pairs of lower limbs was conducted to investigate the accuracy of computer navigation and standard instrumentation for the placement of the Birmingham Hip Resurfacing femoral component. The aim was to place all the femoral components with a stem-shaft angle of 135°.

The mean stem-shaft angle obtained in the standard instrumentation group was 127.7° (120° to 132°), compared with 133.3° (131° to 139°) in the computer navigation group (p = 0.03). The scatter obtained with computer-assisted navigation was approximately half that found using the conventional jig.

Computer navigation was more accurate and more consistent in its placement of the femoral component than standard instrumentation. We suggest that image-free computer-assisted navigation may have an application in aligning the femoral component during hip resurfacing.

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.

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised.

Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.

We report our early experience with a new peri-acetabular reconstruction endoprosthesis used for pelvic reconstruction after tumour resection. The outcome of 21 patients who underwent limb salvage following type II pelvic resection and reconstruction using the peri-acetabular reconstruction prosthesis between 2000 and 2006 was retrospectively reviewed. This prosthesis was designed to use the remaining part of the ilium to support a horizontally placed acetabular component secured with internal fixation and bone cement. Into this device a constrained acetabular liner is positioned which is articulates with a conventional femoral component to which a modular extension and modular head are attached. The mean follow-up was 20.5 months (1 to 77). The most common complications were deep infection, superficial wound infections, and dislocation. The mean musculoskeletal tumor society functional outcome score for the survivors was 20.1(11 to 27).

We recommend the use of the peri-acetabular reconstruction prosthesis for reconstruction of large defects after type II pelvic resection, as this design has a greater inherent stability over other available prostheses.

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.

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004.

Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening.

Post-operatively, the mean maximum flexion was 136° (110° to 140°) in the loosened group and 125° (95° to 140°) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group.

These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.

We have examined the relationship between the size of the flexion gap and the anterior translation of the tibia in flexion during implantation of a posterior cruciate ligament (PCL)-retaining BalanSys total knee replacement (TKR). In 91 knees, the flexion gap and anterior tibial translation were measured intra-operatively using a custom-made, flexible tensor-spacer device.

The results showed that for each increase of 1 mm in the flexion gap in the tensed knee a mean anterior tibial translation of 1.25 mm (SD 0.79, 95% confidence interval 1.13 to 1.37) was produced.

When implanting a PCL-retaining TKR the surgeon should be aware that the tibiofemoral contact point is related to the choice of thickness of the polyethylene insert. An additional thickness of polyethylene insert of 2 mm results in an approximate increase in tibial anterior translation of 2.5 mm while the flexed knee is distracted with a force of between 100 N and 200 N.

The dysplasia cup, which was devised as an adjunct to the Birmingham Hip Resurfacing system, has a hydroxyapatite-coated porous surface and two supplementary neutralisation screws to provide stable primary fixation, permit early weight-bearing, and allow incorporation of morcellised autograft without the need for structural bone grafting.

A total of 110 consecutive dysplasia resurfacing arthroplasties in 103 patients (55 men and 48 women) performed between 1997 and 2000 was reviewed with a minimum follow-up of six years. The mean age at operation was 47.2 years (21 to 62) and 104 hips (94%) were Crowe grade II or III.

During the mean follow-up of 7.8 years (6 to 9.6), three hips (2.7%) were converted to a total hip replacement at a mean of 3.9 years (2 months to 8.1 years), giving a cumulative survival of 95.2% at nine years (95% confidence interval 89 to 100). The revisions were due to a fracture of the femoral neck, a collapse of the femoral head and a deep infection. There was no aseptic loosening or osteolysis of the acetabular component associated with either of the revisions performed for failure of the femoral component. No patient is awaiting a revision.

The median Oxford hip score in 98 patients with surviving hips at the final review was 13 and the 10th and the 90th percentiles were 12 and 23, respectively.

In an adult man the mean femoral anteversion angle measures approximately 15°, for which the reasons have never been fully elucidated.

An assortment of simian and quadruped mammalian femora was therefore examined and the anteversion angles measured. A simple static mathematical model was then produced to explain the forces acting on the neck of the femur in the quadruped and in man. Femoral anteversion was present in all the simian and quadruped femora and ranged between 4° and 41°. It thus appears that man has retained this feature despite evolving from quadrupedal locomotion.

Quadrupeds generally mobilise with their hips flexed forwards from the vertical; in this position, it is clear that anteversion gives biomechanical advantage against predominantly vertical forces. In man with mobilisation on vertical femora, the biomechanical advantage of anteversion is against forces acting mainly in the horizontal plane. This has implications in regard to the orientation of hip replacements.

We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner.

We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle.

Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic.

This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation.

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups.

One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening.

Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively.

No significant difference was found between the two groups.

Achieving deep flexion after total knee replacement remains a challenge. In this study we compared the soft-tissue tension and tibiofemoral force in a mobile-bearing posterior cruciate ligament-sacrificing total knee replacement, using equal flexion and extension gaps, and with the gaps increased by 2 mm each. The tests were conducted during passive movement in five cadaver knees, and measurements of strain were made simultaneously in the collateral ligaments. The tibiofemoral force was measured using a customised mini-force plate in the tibial tray. Measurements of collateral ligament strain were not very sensitive to changes in the gap ratio, but tibiofemoral force measurements were. Tibiofemoral force was decreased by a mean of 40% (sd 10.7) after 90° of knee flexion when the flexion gap was increased by 2 mm. Increasing the extension gap by 2 mm affected the force only in full extension. Because increasing the range of flexion after total knee replacement beyond 110° is a widely-held goal, small increases in the flexion gap warrant further investigation.

We have evaluated four different fixation techniques for the reconstruction of a standard Mason type-III fracture of the radial head in a sawbone model. The outcome measurements were the quality of the reduction, and stability.

A total of 96 fractures was created. Six surgeons were involved in the study and each reconstructed 16 fractures with 1.6 mm fine-threaded wires (Fragment Fixation System (FFS)), T-miniplates, 2 mm miniscrews and 2 mm Kirschner (K-) wires; four fractures being allocated to each method using a standard reconstruction procedure.

The quality of the reduction was measured after definitive fixation. Biomechanical testing was performed using a transverse plane shear load in two directions to the implants (parallel and perpendicular) with respect to ultimate failure load and displacement at 50 N.

A significantly better quality of reduction was achieved using the FFS wires (Tukey’s post hoc tests, p < 0.001) than with the other devices with a mean step in the articular surface and the radial neck of 1.04 mm (sd 0.96) for the FFS, 4.25 mm (sd 1.29) for the miniplates, 2.21 mm (sd 1.06) for the miniscrews and 2.54 mm (sd 0.98) for the K-wires. The quality of reduction was similar for K-wires and miniscrews, but poor for miniplates.

The ultimate failure load was similar for the FFS wires (parallel, 196.8 N (sd 46.8), perpendicular, 212.5 N (sd 25.6)), miniscrews (parallel, 211.8 N (sd 47.9), perpendicular, 208.0 N (sd 65.9)) and K-wires (parallel, 200.4 N (sd 54.5), perpendicular, 165.2 N (sd 37.9)), but significantly worse (Tukey’s post hoc tests, p < 0.001) for the miniplates (parallel, 101.6 N (sd 43.1), perpendicular, 122.7 N (sd 40.7)). There was a significant difference in the displacement at 50 N for the miniplate (parallel, 4.8 mm (sd 2.8), perpendicular, 4.8 mm (sd 1.7)) vs FFS (parallel, 2.1 mm (sd 0.8), perpendicular, 1.9 mm (sd 0.7)), miniscrews (parallel, 1.8 mm (sd 0.5), perpendicular, 2.3 mm (sd 0.8)) and K-wires (parallel, 2.2 mm (sd 1.8), perpendicular, 2.4 mm (sd 0.7; Tukey’s post hoc tests, p < 0.001)).

The fixation of a standard Mason type-III fracture in a sawbone model using the FFS system provides a better quality of reduction than that when using conventional techniques. There was a significantly better stability using FFS implants, miniscrews and K-wires than when using miniplates.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.