This is a 15-year follow-up observational study of 4390 patients with 4606 primary total knee replacements (TKRs) implanted in the Trent health region between 1990 and 1992. The operations were performed in 21 hospitals, including both district general and teaching hospitals, with 77 different surgeons as named consultant.

The main objective was to analyse the survival of the patients and of the prostheses, and to evaluate what impact different variables have on survival. In addition, the 1480 patients (33.7%) (1556 TKRs) alive at 15 years following operation were sent a self-administered questionnaire which examined their level of satisfaction, of pain, and their quality of life at 15 years. Completed responses were received from 912 TKRs (58.6%).

Three survival curves were constructed: a best-case scenario based on the patients entered into the life tables, another included failures not reported in the revision database, and a third worst-case scenario based on all patients lost to follow-up presumed to have had a failed primary TKR. In the best-case scenario survival at 15 years was 92.2%, and in the worst-case scenario was 81.1%. Survival was significantly increased in women and older patients (Mantel-Cox log-rank test, p < 0.005 and p < 0.001, respectively).

Revision as a result of infection was required in 40 TKRs (18.8%) representing 0.87% of the original cohort.

The limited information available from the questionnaire indicated that satisfaction was less frequent among men, patients with osteoarthritis and those who required revision (chi-squared test, p < 0.05, p < 0.05 and p < 0.0001, respectively). With regard to pain, older patients, females and patients who still had their primary replacement in place at 15 years, reported the least pain (chi-squared test for trends, p < 0.0005, p < 0.005 and p < 0.0001, respectively). The reported quality of life was not affected by any variable.

We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular en bloc excision. All had a pedicled myocutaneous latissimus dorsi rotation flap for soft-tissue cover and reconstruction of the triceps. Wide negative surgical margins were obtained in all five patients. No local wound complications or infections were seen. There were no local recurrences at a mean follow-up of 60 months (20 to 105). The functional results were excellent in four patients and good in one. Longer term follow-up is necessary to confirm the durability of the elbow reconstruction.

Disorders of the pisotriquetral joint are well recognised as the cause of pain on the ulnar side of the wrist. The joint is not usually examined during routine arthroscopy because it is assumed to have a separate joint cavity to the radiocarpal joint, although there is often a connection between the two.

We explored this connection during arthroscopy and in fresh-frozen cadaver wrists and found that in about half of the cases the pisotriquetral joint could be visualised through standard wrist portals. Four different types of connection were observed between the radiocarpal joint and the pisotriquetral joint. They ranged from a complete membrane separating the two, to no membrane at all, with various other types of connection in between.

We recommend that inspection of the pisotriquetral joint should be a part of the protocol for routine arthroscopy of the wrist.

Three-dimensional surface models of the normal hemipelvis derived from volumetric CT data on 42 patients were used to determine the radius, depth and orientation of the native acetabulum. A sphere fitted to the lunate surface and a plane matched to the acetabular rim were used to calculate the radius, depth and anatomical orientation of the acetabulum. For the 22 females the mean acetabular abduction, anteversion, radius and normalised depth were 57.1° (50.7° to 66.8°), 24.1° (14.0° to 33.3°), 25 mm (21.7 to 30.3) and 0.79 mm (0.56 to 1.04), respectively. The same parameters for the 20 males were 55.5° (47.7° to 65.9°), 19.3° (8.5° to 32.3°), 26.7 mm (24.5 to 28.7) and 0.85 mm (0.65 to 0.99), respectively.

The orientation of the native acetabulum did not match the safe zone for acetabular component placement described by Lewinnek. During total hip replacement surgeons should be aware that the average abduction angle of the native acetabulum exceeds that of the safe zone angle. If the concept of the safe zone angle is followed, abduction of the acetabular component should be less than the abduction of the native acetabulum by approximately 10°.

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0).

A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity.

We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.

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.

Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative.

Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection.

We describe the influence of the angle of immobilisation during partial weight-bearing on the forces across the extensor mechanism of the knee. Gait analysis was performed on eight healthy male subjects with the right knee in an orthotic brace locked at 0°, 10°, 20° and 30°, with the brace unlocked and also without a brace. The ground reaction force, the angle of the knee and the net external flexion movement about the knee were measured and the extensor mechanism force was calculated.

The results showed a direct non-linear relationship between the angle of knee flexion and the extensor mechanism force. When a brace was applied, the lowest forces occurred when the brace was locked at 0°. At 30° the forces approached the failure strength of some fixation devices. We recommend that for potentially unstable injuries of the extensor mechanism, when mobilising with partial weight-bearing, the knee should be flexed at no more than 10°.

We have reviewed 54 patients who had undergone 61 total hip replacements using bulk femoral autografts to augment a congenitally dysplastic acetabulum. There were 52 women and two men with a mean age of 42.4 years (29 to 76) at the time of the index operation. A variety of different prostheses was used: 28 (45.9%) were cemented and 33 (54.1%) uncemented. The graft technique remained unchanged throughout the series.

Follow-up was at a mean of 8.3 years (3 to 20). The Hospital for Special Surgery hip score improved from a mean of 10.7 (4 to 18) pre-operatively to a mean of 35 (28 to 38) at follow-up.

The position of the acetabular component was anatomical in 37 hips (60.7%), displaced less than 1 cm in 20 (32.7%) and displaced more than 1 cm in four (6.6%). Its cover was between 50% and 75% in 34 hips (55.7%) and less than 50% in 25 (41%). In two cases (3.3%), it was more than 75%.

There was no graft resorption in 36 hips (59%), mild resorption in 21 (34%) and severe resorption in four (6%).

Six hips (9.8%) were revised for aseptic loosening. The overall rate of loosening and revision was 14.8%. Overall survival at 8.3 years was 93.4%.

The only significant factor which predicted failure was the implantation of the acetabular component more than 1 cm from the anatomical centre of rotation of the hip.

We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35).

The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5° (95° to 135°) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation.

Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.

We report a case of Lemierre’s syndrome complicated by an epidural abscess. This manifestation of Lemierre’s syndrome has not been described previously.

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.

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed.

Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31)

In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.

We have evaluated in vitro the accuracy of percutaneous and ultrasound registration as measured in terms of errors in rotation and version relative to the bony anterior pelvic plane in computer-assisted total hip replacement, and analysed the intra- and inter-observer reliability of manual or ultrasound registration.

Four clinicians were asked to perform registration of the landmarks of the anterior pelvic plane on two cadavers. Registration was performed under four different conditions of acquisition. Errors in rotation were not significant. Version errors were significant with percutaneous methods (16.2°; p < 0.001 and 19.25° with surgical draping; p < 0.001), but not with the ultrasound acquisition (6.2°, p = 0.13). Intra-observer repeatability was achieved for all the methods. Inter-observer analysis showed acceptable agreement in the sagittal but not in the frontal plane.

Ultrasound acquisition of the anterior pelvic plane was more reliable in vitro than the cutaneous digitisation currently used.

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 retrospectively identified 18 consecutive patients with synovial chrondromatosis of the shoulder who had arthroscopic treatment between 1989 and 2004. Of these, 15 were available for review at a mean follow-up of 5.3 years (2.3 to 16.5). There were seven patients with primary synovial chondromatosis, but for the remainder, the condition was a result of secondary causes. The mean Constant score showed that pain and activities of daily living were the most affected categories, being only 57% and 65% of the values of the normal side. Surgery resulted in a significant improvement in the mean Constant score in these domains from 8.9 (4 to 15) to 11.3 (2 to 15) and from 12.9 (5 to 20) to 18.7 (11 to 20), respectively (unpaired t-test, p = 0.04 and p < 0.0001, respectively). Movement and strength were not significantly affected. Osteoarthritis was present in eight patients at presentation and in 11 at the final review. Recurrence of the disease with new loose bodies occurred in two patients from the primary group at an interval of three and 12 years post-operatively. In nine patients, loose bodies were also present in the bicipital groove; seven of these underwent an open bicipital debridement and tenodesis.

We found that arthroscopic debridement of the glenohumeral joint and open debridement and tenodesis of the long head of biceps, when indicated, are safe and effective in relieving symptoms at medium-term review.

Desiccation of articular cartilage during surgery is often unavoidable and may result in the death of chondrocytes, with subsequent joint degeneration. This study was undertaken to determine the extent of chondrocyte death caused by exposure to air and to ascertain whether regular rewetting of cartilage could decrease cell death.

Macroscopically normal human cartilage was exposed to air for 0, 30, 60 or 120 minutes. Selected samples were wetted in lactated Ringer’s solution for ten seconds every ten or 20 minutes. The viability of chondrocytes was measured after three days by Live/Dead staining.

Chondrocyte death correlated with the length of exposure to air and the depth of the cartilage. Drying for 120 minutes caused extensive cell death mainly in the superficial 500 μm of cartilage. Rewetting every ten or 20 minutes significantly decreased cell death.

The superficial zone is most susceptible to desiccation. Loss of superficial chondrocytes likely decreases the production of essential lubricating glycoproteins and contributes to subsequent degeneration. Frequent wetting of cartilage during arthrotomy is therefore essential.

We report the results of our continued review of 11 total hip arthroplasties using 22.225 mm alumina ceramic femoral heads on a Charnley flanged stem, articulating with chemically cross-linked polyethylene. There was an initial bedding-in of up to 0.41 mm at the articular surface in the first two years. This had not progressed further, at a minimum follow-up of 15 years. Radiographically no femoral or acetabular component showed loosening or osteolysis.