We carried out a prospective study to assess the clinical outcome, complications and survival of the NexGen Legacy posterior-stabilised-Flex total knee replacement (TKR) in a consecutive series of 278 knees between May 2003 and February 2005. Mean follow-up for 259 TKRs (98.2%) was 3.8 years (3.0 to 4.8). Annual follow-up showed improvement in the Knee Society scores (paired t-test, p < 0.05). At the last follow-up, the mean maximum flexion was 135° (110° to 150°). Two knees showed radiolucent lines, but revision was not required because the patients were asymptomatic. Revision was required in one case because of infection, but there were no prosthesis-related revisions. There were no other complications. The estimated survival rate at four years with revision for any reason and prosthesis-related problems was 99.6% and 100%, respectively.

This relatively large study indicates that the legacy posterior stabilised-Flex design provides excellent short-term outcome but warrants ongoing evaluation to confirm the long-term durability and functioning of the implant.

The routine use of surgical drains in total hip arthroplasty remains controversial. They have not been shown to decrease the rate of wound infection significantly and can provide a retrograde route for it. Their use does not reduce the size or incidence of post-operative wound haematomas. This prospective, randomised study was designed to evaluate the role of drains in routine total hip arthroplasty.

We investigated 552 patients (577 hips) undergoing unilateral or bilateral total hip arthroplasty who had been randomised to either having a drain for 24 hours or not having a drain. All patients followed standardised pre-, intra-, and post-operative regimes and were independently assessed using the Harris hip score before operation and at six, 18 and 36 months follow-up.

The rate of superficial and deep infection was 2.9% and 0.4%, respectively, in the drained group and 4.8% and 0.7%, respectively in the undrained group. One patient in the undrained group had a haematoma which did not require drainage or transfusion. The rate of transfusion after operation in the drained group was significantly higher than for undrained procedures (p < 0.042). The use of a drain did not influence the post-operative levels of haemoglobin, the revision rates, Harris hip scores, the length of hospital stay or the incidence of thromboembolism. We conclude that drains provide no clear advantage at total hip arthroplasty, represent an additional cost, and expose patients to a higher risk of transfusion.

We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee.

OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees.

We consider that skin staples are the skin closure of choice for both hip and knee replacements.

The Oxford unicompartmental knee replacement (UKR) was designed to minimise wear utilising a fully-congruent, mobile, polyethylene bearing. Wear of polyethylene is a significant cause of revision surgery in UKR in the first decade, and the incidence increases in the second decade. Our study used model-based radiostereometric analysis to measure the combined wear of the upper and lower bearing surfaces in 13 medial-compartment Oxford UKRs at a mean of 20.9 years (17.2 to 25.9) post-operatively.

The mean linear penetration of the polyethylene bearing was 1.04 mm (0.307 to 2.15), with a mean annual wear rate of 0.045 mm/year (0.016 to 0.099). The annual wear rate of the phase-2 bearings (mean 0.022 mm/year) was significantly less (p = 0.01) than that of phase-1 bearings (mean 0.07 mm/year).

The linear wear rate of the Oxford UKR remains very low into the third decade. We believe that phase-2 bearings had lower wear rates than phase-1 implants because of the improved bearing design and surgical technique which decreased the incidence of impingement. We conclude that the design of the Oxford UKR gives low rates of wear in the long term.

New developments in osteotomy techniques and methods of fixation have caused a revival of interest of osteotomies around the knee. The current consensus on the indications, patient selection and the factors influencing the outcome after high tibial osteotomy is presented. This paper highlights recent research aimed at joint pressure redistribution, fixation stability and bone healing that has led to improved surgical techniques and a decrease of post-operative time to full weight-bearing.

Multiple drilling is reported to be an effective treatment for osteonecrosis of the head of femur, but its effect on intra-osseous pressure has not been described. We undertook multiple drilling and recorded the intra-osseous pressure in 75 osteonecrotic hips in 60 patients with a mean age of 42 years (19 to 67). At a mean follow-up of 37.1 months (24 to 60), 42 hips (56%) had a clinically successful outcome. The procedure was effective in reducing the mean intra-osseous pressure from 57 mmHg (SD 22) to 16 mmHg (SD 9). Hips with a successful outcome had a mean pressure of 26 mmHg (SD 19). It was less effective in preventing progression of osteonecrosis in hips with considerable involvement and in those with a high intra-osseous pressure in the intertrochanteric region (mean 45 mmHg (SD 25)). This study is not able to answer whether a return of the intra-osseous pressure to normal levels is required for satisfactory healing.

Pain is the main indication for performing total knee replacement (TKR). In most patients after TKR there is an improvement, but a few continue to have pain. Generally, the cause of the pain can be addressed when it is identified. However, unexplained pain can be more difficult to manage because revision surgery is likely to be unrewarding in this group. In our study of 622 cemented TKRs in 512 patients with a mean age of 69 years (23 to 90) treated between January 1995 and August 1998, we identified 24 patients (knees) with unexplained pain at six months. This group was followed for five years (data was unavailable for 18 knees) and ten patients (55.5%) went on to show an improvement without intervention.

In the case of unexplained pain, management decisions must be carefully considered, but reassurance can be offered to patients that the pain will improve in more than half with time.

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.

Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.

Autologous chondrocyte implantation is an established method of treatment for symptomatic articular defects of cartilage. CARTIPATCH is a monolayer-expanded cartilage cell product which is combined with a novel hydrogel to improve cell phenotypic stability and ease of surgical handling. Our aim in this prospective, multicentre study on 17 patients was to investigate the clinical, radiological, arthroscopic and histological outcome at a minimum follow-up of two years after the implantation of autologous chondrocytes embedded in a three-dimensional alginate-agarose hydrogel for the treatment of chondral and osteochondral defects.

Clinically, all the patients improved significantly. Patients with lesions larger than 3 cm² improved significantly more than those with smaller lesions. There was no correlation between the clinical outcome and the body mass index, age, duration of symptoms and location of the defects. The mean arthroscopic International Cartilage Repair Society score was 10 (5 to 12) of a maximum of 12. Predominantly hyaline cartilage was seen in eight of the 13 patients (62%) who had follow-up biopsies.

Our findings suggest that autologous chondrocyte implantation in combination with a novel hydrogel results in a significant clinical improvement at follow-up at two years, more so for larger and deeper lesions. The surgical procedure is uncomplicated, and predominantly hyaline cartilage-like repair tissue was observed in eight patients.

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.

We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally aspirin, hypotensive epidural anaesthesia, elastic compression stockings and early mobilisation. In 258 of these procedures (244 patients) performed in 2005 (cohort A) mechanical compression devices were not used, whereas in 229 (219 patients) performed during 2006 (cohort B) bilateral intermittent pneumatic calf compression was used.

All operations were performed through a posterior mini-incision approach. Patients who required anticoagulation for pre-existing medical problems and those undergoing revision arthroplasty were excluded. Doppler ultrasonographic screening for deep-vein thrombosis was performed in all patients between the fourth and sixth post-operative days. All patients were reviewed at a follow-up clinic six to ten weeks after the operation. In addition, reponse to a questionnaire was obtained at the end of 12 weeks post-operatively.

No symptomatic calf or above-knee deep-vein thrombosis or pulmonary embolism occurred. In 25 patients in cohort A (10.2%) and in ten patients in cohort B (4.6%) asymptomatic calf deep-vein thromboses were detected ultrasonographically. This difference was statistically significant (p = 0.03). The regimen followed by cohort B offers the prospect of a low incidence of venous thromboembolism without subjecting patients to the higher risk of bleeding associated with anticoagulant use.

We examined the placement of the stem in relation to the medial tibial cortex when using total knee replacements (TKRs) with medially-offset tibial stems in Korean patients. Measurements were performed on the pre- and post-operative radiographs of 246 osteoarthritic knees replaced between January 2005 and May 2006 using the Genesis II or E-motion TKR with a medially-offset stem. Pre-operatively, we measured the distance between the mechanical axis and that of the tibial shaft and post-operatively, that between the midline of the tibial stem and the axis of the shaft.

Knees were identified in which there was radiological contact between the tip of the stem and the medial tibial cortex. The mechanical axis was located medial to the axis of the shaft in 203 knees (82.5%). Post-operatively, the midline of the tibial stem was located medial to the tibial shaft axis in 196 knees (79.7%). In 16 knees (6.5%) there was radiological contact between the tibial stem or cement mantle and the medial tibial cortex.

Our study has shown that the medially-offset stem in the tibial component may not be a good option for knees undergoing replacement for advanced osteoarthritis in some Korean patients.

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. The natural history of narrowing of the femoral neck is unknown. We retrospectively measured the diameter of the femoral neck in a series of 163 Birmingham hip resurfacings in 163 patients up to a maximum of six years after operation to determine the extent and progression of narrowing.

There were 105 men and 58 women with a mean age of 52 years (18 to 82). At a mean follow-up of five years, the mean Harris hip score was 94.8 (47 to 100) and the mean flexion of the hip 112.5° (80° to 160°). There was some narrowing of the femoral neck in 77% (125) of the patients reviewed, and in 27.6% (45) the narrowing exceeded 10% of the diameter of the neck. A multiple logistic regression analysis showed a significant association (chi-squared test (derived from logistic regression) p = 0.01) of narrowing with female gender and a valgus femoral neck/shaft angle. There was no significant association between the range of movement, position or size of the component or radiological lucent lines and narrowing of the neck (chi-squared test; p = 0.10 (flexion), p = 0.08 (size of femoral component), p = 0.09 (size of acetabular component), p = 0.71 (femoral component angulation), p = 0.99 (lucent lines)). There was no significant difference between the diameter of the neck at a mean of three years (2.5 to 3.5) and that at five years (4.5 to 5.5), indicating that any change in the diameter of the neck had stabilised by three years (sign rank test, p = 0.60).

We conclude that narrowing of the femoral neck which is found with the Birmingham hip resurfacing arthroplasty is in most cases associated with no adverse clinical or radiological outcome up to a maximum of six years after the initial operation.

We performed a randomised, controlled trial involving 150 patients with a pre-operative level of haemoglobin of 13.0 g/dl or less, to compare the effect of either topical fibrin spray or intravenous tranexamic acid on blood loss after total knee replacement.

A total of 50 patients in the topical fibrin spray group had 10 ml of the reconstituted product applied intra-operatively to the operation site. The 50 patients in the tranexamic acid group received 500 mg of tranexamic acid intravenously five minutes before deflation of the tourniquet and a repeat dose three hours later, and a control group of 50 patients received no pharmacological intervention.

There was a significant reduction in the total calculated blood loss for those in the topical fibrin spray group (p = 0.016) and tranexamic acid group (p = 0.041) compared with the control group, with mean losses of 1190 ml (708 to 2067), 1225 ml (580 to 2027), and 1415 ml (801 to 2319), respectively. The reduction in blood loss in the topical fibrin spray group was not significantly different from that achieved in the tranexamic acid group (p = 0.72).

The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening.

These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.

We investigated the factors related to the radiological outcome of a transtrochanteric curved varus osteotomy in patients with osteonecrosis of the hip. We reviewed 73 hips in 62 patients with a mean follow-up of 12.4 years (5 to 31.1). There were 28 men and 34 women, with a mean age of 33.3 years (15 to 68) at the time of surgery. The 73 hips were divided into two groups according to their radiological findings: group 1 showed progression of collapse and/or joint-space narrowing; group 2 had neither progressive collapse nor joint-space narrowing. Both of these factors and the radiological outcomes were analysed by a stepwise discriminant analysis. A total of 12 hips were categorised as group 1 and 61 as group 2. Both the post-operative intact ratio and the localisation of the necrotic lesion correlated with the radiological outcome. The cut-off point of the postoperative intact ratio to prevent the progression of collapse was 33.6%, and the cut-off point to prevent both the progression of collapse and joint-space narrowing was 41.9%.

The results of this study indicate that a post-operative intact ratio of 33.0% is necessary if a satisfactory outcome is to be achieved after this varus osteotomy.

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.

We have examined the differences in clinical outcome of total knee replacement (TKR) with and without patellar resurfacing in a prospective, randomised study of 181 osteoarthritic knees in 142 patients using the Profix total knee system which has a femoral component with features considered to be anatomical and a domed patellar implant.

The procedures were carried out between February 1998 and November 2002. A total of 159 TKRs in 142 patients were available for review at a mean of four years (3 to 7). The patients and the clinical evaluator were blinded in this prospective study. Evaluation was undertaken annually by an independent observer using the knee pain scale and the Knee Society clinical rating system. Specific evaluation of anterior knee pain, stair-climbing and rising from a seated to a standing position was also undertaken.

No benefit was shown of TKR with patellar resurfacing over that without resurfacing with respect to any of the measured outcomes. In 22 of 73 knees (30.1%) with and 18 of 86 knees (20.9%) without patellar resurfacing there was some degree of anterior knee pain (p = 0.183). No revisions related to the patellofemoral joint were performed in either group. Only one TKR in each group underwent a re-operation related to the patellofemoral joint. A significant association between knee flexion contracture and anterior knee pain was observed in those knees with patellar resurfacing (p = 0.006).

Between 1988 and 1998 we implanted 318 total hip replacements (THRs) in 287 patients using the Plasmacup (B. Braun Ltd, Sheffield, United Kingdom) and a conventional metal-on-polyethylene articulation. The main indications for THR were primary or secondary osteoarthritis.

At follow-up after a mean 11.6 years (7.6 to 18.4) 17 patients had died and 20 could not be traced leaving a final series of 280 THRs in 250 patients. There were 62 revisions (22.1%) in 59 patients. A total of 43 acetabular shells (15.4%) had been revised and 13 (4.6%) had undergone exchange of the liner. The most frequent indications for revision were osteolysis and aseptic loosening, followed by polyethylene wear. The mean Kaplan-Meier survival of the Plasmacup was 91% at ten years and 58% at 14 years. Osteolysis was found around 36 (17.1%) of the 211 surviving shells. The median annual rate of linear wear in the surviving shells was 0.12 mm/year and 0.25 mm/year in those which had been revised (p < 0.001). Polyethylene wear was a strong independent risk factor for osteolysis and aseptic loosening. The percentage of patients with osteolysis increased proportionately with each quintile of wear-rate.

There is a high late rate of failure of the Plasmacup. Patients with the combination of this prosthesis and bearing should be closely monitored after ten years.

Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell.

Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%).

At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis.

Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.