We took posteroanterior weight-bearing radiographs, both with the joint fully extended and in 30° of flexion, in a consecutive series of 50 knees in 37 patients referred for the primary assessment of pain and/or stiffness. These radiographs were reported ‘blind’ both by an orthopaedic surgeon and a radiologist. Direct measurement of the joint space, together with grading of the severity of erosion according to the Ahlback criteria, was undertaken. Any other abnormality present was also documented. The radiographs of the knees in 30° of flexion consistently showed more advanced erosion in both the medial (p = 0.001) and the lateral (p = 0.0001) tibiofemoral compartments, when compared with those of knees in full extension. The Ahlback classification of 25 joints was altered, in some cases by several grades, by the flexed position of the joint. In every case in which another abnormality was identified on the radiograph in full extension, it was also noted on that of the knee in 30° of flexion. In a further four cases, additional pathology could only be seen in the flexed knee. Every patient was able to complete the radiological examination without difficulty. Our study supports the adoption of a weight-bearing view in 30° of flexion as the standard posteroanterior radiograph for the assessment of tibiofemoral osteoarthritis in patients over 50 years of age

Aims

In previous studies, we identified multiple factors influencing the survivorship of hip resurfacing arthroplasties (HRAs), such as initial anatomical conditions and surgical technique. In addition, the University of California, Los Angeles (UCLA) activity score presents a ceiling effect, so a better quantification of activity is important to determine which activities may be advisable or detrimental to the recovered patient. We aimed to determine the effect of specific groups of sporting activities on the survivorship free of aseptic failure of a large series of HRA.

Our aim was to define the minimum set of patient-reported outcome measures which are required to assess health status after total hip replacement (THR). In 114 patients, we compared the pre-operative characteristics and sensitivity to change of the Oxford hip score (OHS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), the SF-36, the SF-12 (derived from the SF-36), and the Euroqol questionnaire (EQ-5D). At one year after operation, very large effect sizes were found for the disease-specific measures, the physical domains of the SF-12, SF-36 and the EQ-5D. index. (1.3 to 3.0). Patients in Charnley class A showed more change in the OHS, WOMAC pain and function, the physical domains of the SF-36 and the EQ-5D. vas. (p < 0.05) compared with those in the Charnley B and C group. In this group, the effect size for the OHS more than doubled the effect sizes of WOMAC pain and physical function. We found high correlations and correlations of change between the OHS, the WOMAC, the physical domains of the SF-12 and the SF-36 and EQ-5D. index. The SF-36 and EQ-5D scores at one year after operation approached those of the general population. Furthermore, we found a binomial distribution of the pre-operative EQ-5D. index. score and a pre-operative discrepancy and post-operative agreement between the EQ-5D. vas. and EQ-5D. index. . We recommend the use of the OHS and SF-12 in the assessment of THR. The SF-36 may be used in circumstances when smaller changes in health status are investigated, for example in the follow-up of THR. The EQ-5D is useful in situations in which utility values are needed in order to calculate cost-effectiveness or quality-adjusted life years (QALYs), such as in the assessment of new techniques in THR

The clinical features of nine new patients with dysplasia epiphysialis hemimelica are reported, with a long-term follow-up on a further seven patients who were described in the earliest case reports of this disease. Each of these 16 patients had only one leg involved, but 12 had multiple epiphyses affected. The distal femur, distal tibia and talus were the commonest sites and most patients presented with painless swelling or deformity. Wasting of the muscles of the affected leg was a common finding, and was occasionally disproportionate to the degree of disuse. One patient had the unique combination of involvement of the lateral and medial halves of different epiphyses in the same limb and another had unusual metaphysial changes. Diagnosis was often delayed despite typical radiographic appearances. There was no evidence for a genetic component in the aetiology nor was any common environmental factor identified. Treatment by local excision was generally effective for lesions in the vicinity of the knee, but some patients with involvement of the talus required arthrodesis around the ankle. The long-term prognosis appears to be good and so far only two of these patients have developed premature osteoarthritis

The purpose of the work described was to find the average pressure on each of several areas of the acetabular cartilage of the cadaver hip under physiological loads. By obtaining load-deflection curves for one chosen area of cartilage, firstly with all the cartilage present and then after the successive removal of other areas, the fractions of the original load carried by the several areas were found, and hence the average pressures on those areas. Seventeen hips (age range twenty. two to eighty-seven years) were examined. Local pressures varied from zero to 3.4 times the average pressure in each hip. The highest pressures in the series (about 4 to 5 megaNewtons per square metre) were on areas of thin fibrocartilage which were identified at the zenith of certain acetabula. The results are too few to establish whether or not the pressure distribution was age-related. The higher pressures found are within the range which in other experiments has led to fatigue failure of femoral head cartilage, and it is suggested that hips in which such pressures exist under loads of three times body weight may be predisposed to osteoarthritis

1. In a previous investigation, approximately 40 per cent of so-called "primary" degenerative disease or osteoarthritis of the hip appeared to have been the result of an abnormal joint mechanism caused by minimal epiphysiolysis in adolescence. Males were affected much more commonly than females. The residual abnormality of this disturbance, recognised radiologically, was termed the "tilt deformity" of the femoral head. 2. Three groups of young adult males, with different athletic backgrounds, have now been examined to assess the incidence of this abnormality and its relationship to athletic regimes. The condition was found to be more common in subjects who had been engaged in more active regimes and was also related statistically to a history of "growing pains". The deformity is compared with the gross disturbance of adolescent epiphysiolysis or slipped epiphysis, which is believed basically to be caused by chronic stress. 3. Degenerative disease of the hip of this type has a geographical and racial distribution corresponding to the degree of interest in and encouragement of competitive athletic activities. Many cases are therefore postulated to be the direct result of a minor and usually asymptomatic disturbance of this type, attributable to excess activity during adolescence

1. One hundred and twenty cervical spines removed at routine necropsy from elderly patients dying in a general hospital have been examined. 2. There was some degree of degeneration of intervertebral discs in 110 cases–in forty-six this was severe. 3. Degenerative disc disease was found at an earlier age in men; mild damage preceded severe degeneration and collapse by about a decade. 4. Discs of the lower spine were most frequently and most severely affected. 5. Alterations of the normal cervical lordosis were produced by disc disease in thirty-two cases. 6. Osteoarthritis of the apophysial joints was found in seventy-eight, and by contrast to disc degeneration was commonest in the mid-cervical and upper cervical regions. In eighteen it was severe. 7. Degeneration and scarring of nerve roots was frequently associated with diseased discs; apophysial joint arthritis was found to be an important additional factor when it occurred in the lower cervical region. 8. No nerve root changes could be attributed to ischaemia resulting from narrowing or distortion of the vertebral arteries. 9. Cystic arachnoidal diverticula which excavate the posterior root ganglia were found in thirty-six cases

1. The term "observation hip" refers to a form of hip disease affecting children and adolescents, the most significant features being the transient nature of the symptoms and the absence of a bony or cartilaginous lesion on radiographic examination. 2. With a view to determining the possible sequelae of the disorder, twenty-three patients aged between two and fifteen years at the onset of the condition were studied fifteen to thirty years later. 3. Varying degrees of coxa magna, osteoarthritis or simple broadening of the femoral neck in the "observed" hip joint were found in the radiographs of twelve of the twenty-three patients studied. 4. This analysis suggests that the " observation hip" syndrome is the result ofan inflammatory process ofthejoint due to varied etiology, whether from injury or infection. The developmental and degenerative changes which may occur are a consequence of hypervascularisation of the bone. Thus changes may develop without necessarily producing the epiphysial necrosis characteristic of the first stage of ischaemia in Legg-Calvé-Perthes' disease. 5. The persistence of this stage of hypervascularity, and therefore the possible outcome of the transient synovitis, may be conditioned by the age at onset of the pathological process, the severity of the condition, and the duration of the symptoms and signs

We report the incidence of osteolysis in the femur, tibia, and patella of 44 consecutive patients (60 knees) who were followed for more than seven years after cementless knee arthroplasty with a Porous-Coated Anatomic prosthesis. The average age of the patients was 56.5 years (17 to 73); the operative diagnosis was osteoarthritis (33 knees), rheumatoid arthritis (17), tuberculous arthritis (7) and post-traumatic arthritis (3). All patellae were resurfaced. No femoral or tibial component was loose at the final follow-up examination. Thirty patellar components were loose of which six had been revised. Radiographs revealed osteolysis in 90% of the tibial plateaux and in 80% of the 30 intact patellar prostheses. No osteolysis was seen around any femoral component. In 50 knees (83%) the average wear of the polyethylene liner was 2.5 mm in the medial compartment and 1.7 mm in the lateral compartment. Four of 60 knees (6.7%) were revised for complete wear of the polyethylene liner of the tibial component. Fixation of the tibial and patellar components without cement fails to seal the interface between bone and prosthesis and allows the migration of polyethylene particulate debris which causes osteolysis

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis

We studied serial CT scans of 45 arthritic shoulders (34 rheumatoid, 11 osteoarthritic) and 19 normal shoulders, making measurements at three levels on axial images. The maximum anteroposterior diameter of the glenoid was increased in rheumatoid glenoids at the upper and middle levels by 6 mm and in osteoarthritic glenoids at all levels by 5 to 8 mm as compared with normal. In rheumatoid cases, nearly half the available surface of the glenoid was of unsupported bone, mainly posteriorly at the upper and middle levels. In osteoarthritic glenoids, the best supported bone was anterior at the upper level and central at the middle and lower levels. The depth of the rheumatoid glenoid was reduced by a mean of 6 mm at the upper and middle levels and by 3 mm at the lower level. This inclined the surface of the glenoid superiorly. The depth at the middle level in osteoarthritis was reduced by a mean of 5 mm, suggesting central protrusion. Osteoarthritic glenoids were retroverted by a mean of 12.5 degrees, but of rheumatoid glenoids two-thirds were retroverted (mean 15.1 degrees) and one-third anteverted (mean 8.2 degrees). Our findings have important implications for the planning and placement of the glenoid component of total shoulder replacements; CT can provide useful information

From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries

One of the objectives of knee replacement is to correct flexion deformity, the frequent consequence of rheumatoid arthritis and osteoarthritis. A review of 697 primary and revision replacements carried out between 1969 and 1985 and followed up from 1 to 16 years found that such deformity was present in 61% of knees before the primary operation. Replacement reduced this to 17% and the improvement was usually maintained. The deformity was present in only 21% of the replacements which required revision and the second operation reduced this to 8%. Flexion contractures affected rheumatoid knees more often and more seriously than osteoarthritic knees, but arthroplasty was more successful in correcting the deformity in the former. All of the 11 types of prosthesis used achieved some degree of correction, but the Walldius hinge and the variants of the Freeman condylar design were the most successful. Surprisingly, the best outcome, in terms of pain and reduced need for revision, was found in the rheumatoid knees most seriously deformed before operation, but this association was absent in the osteoarthritic knees. Postoperative deformity in knees without pain or extreme weakness did not appear to influence the patients' ability to walk or to use stairs or a chair, as measured by unexacting tests in the clinic

1. Forty-five patients with monarthritis of at least six months duration have been reviewed. Arthrotomy and synovial biopsy were carried out in every case. The period of follow-up varied from two to eight years from the time of biopsy. A re-examination of the biopsy material was made at the time of clinical assessment. 2. Twelve patients (27 per cent) were diagnosed as having definite or probable rheumatoid arthritis. Four patients (9 per cent) had psoriatic arthropathy and six (13 per cent) had a persistent monarthritis of undetermined type. A further four patients (9 per cent) had polyarthritis of undetermined type, ten (22 per cent) were diagnosed as having osteoarthritis and seven (16 per cent) were completely normal (self-limiting joint disease). 3. There was a moderately good relationship between biopsy findings suggestive of rheumatoid arthritis and the eventual clinical outcome. 4. Monarthritis of the wrist was followed in every case by the development of significant disease, either rheumatoid arthritis or psoriatic arthropathy. 5. Rheumatoid arthritis may remain monarticular for many years. 6. It is concluded that thorough investigation of patients with monarthritis is of considerable help in diagnosis and prognosis

From 1981 to 1983, we implanted Bioceram type-4 and type-5 prostheses in 61 hips in 54 patients with osteoarthritis secondary to acetabular dysplasia, congenital subluxation, or congenital dislocation of the hip. Fifty-seven hips in 50 patients were followed for a mean of 11.1 years (10 to 13). The mean age of the patients at operation was 53 years (31 to 70). Functional evaluation using the Merle d'Aubigne and Postel hip score showed a 77% success rate. Radiological loosening occurred in three femoral (5%) and 16 acetabular components (28%). Autologous femoral head grafts were used in 18 hips and became incorporated, giving mechanical support to the socket except for one which occupied a large weight-bearing area and eventually collapsed. The mean polyethylene wear was 1.1 mm (0 to 3.6) and the mean wear rate was 0.10 mm/year (0 to 0.31). A high rate of wear correlated with calcar resorption (p > 0.002) but not with acetabular loosening. There was no breakage of a ceramic head. Study of the ceramic heads and polyethylene sockets retrieved after ten years showed excellent surface roughness, sphericity, and bending strength for the heads but scratches and voids were seen on the sockets

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty

We treated 31 consecutive patients of mean age 43 years (22 to 59) with severe osteoarthritis of the hip secondary to dysplasia by valgus-extension osteotomy. The clinical results were analysed for factors which may have affected the outcome. The procedure was carried out only on one side and was combined with a Chiari pelvic osteotomy in four patients. The angle of valgus was between 30 and 40° with 10 to 20° of extension. The mean follow-up was 15 years (12 to 18). Clinical evaluation using Charnley’s modification of the system of Merle d’Aubigné and Postel showed that the mean score for pain had improved from 2.3 before operation to 4.2 at 15 years, and function from 2.3 to 4.2. Range of movement had decreased from 4.2 to 3.5. Fifteen patients (48.4%) had a pain score of 5 or 6 and were evaluated as satisfactory. Kaplan-Meier survivorship analysis showed a survival rate of 51% at 15 years after operation. Two preoperative factors had a significant positive correlation with the radiological results, namely the thickness of the capital drop osteophyte and the length of the roof osteophyte. We suggest that this procedure is effective for advanced osteoarthritis in the dysplastic hip in young and active patients if these factors are satisfactory on the preoperative radiographs

Objectives

Modern metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), while achieving good results with well-orientated, well-designed components in ideal patients, is contraindicated in women, men with head size under 50 mm, or metal hypersensitivity. These patients currently have no access to the benefits of HRA. Highly crosslinked polyethylene (XLPE) has demonstrated clinical success in total hip arthroplasty (THA) and, when used in HRA, potentially reduces metal ion-related sequelae. We report the early performance of HRA using a direct-to-bone cementless mono-bloc XLPE component coupled with a cobalt-chrome femoral head, in the patient group for whom HRA is currently contraindicated.