It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age

Increasing follow-up identifies the outcome in younger patients who have undergone total hip replacement (THR) and reveals the true potential for survival of the prosthesis. We identified 28 patients (39 THRs) who had undergone cemented Charnley low friction arthroplasty between 1969 and 2001. Their mean age at operation was 17.9 years (12 to 19) and the maximum follow-up was 34 years. Two patients (4 THRs) were lost to follow-up, 13 (16 THRs) were revised at a mean period of 19.1 years (8 to 34) and 13 (19 THRs) continue to attend regular follow-up at a mean of 12.6 years (2.3 to 29). In this surviving group one acetabular component was radiologically loose and all femoral components were secure. In all the patients the diameter of the femoral head was 22.225 mm with Charnley femoral components used in 29 hips and C-stem femoral components in ten. In young patients who require THR the acetabular bone stock is generally a limiting factor for the size of the component. Excellent long-term results can be obtained with a cemented polyethylene acetabular component and a femoral head of small diameter

A series of 400 patients (average age 57.7 years) with bilateral low-friction arthroplasties of the hip has been reviewed. Comparison was made with similar unilateral operations. The results showed that the bilateral arthroplasties can be carried out as a single operation without higher risk of local or general complications. However, this excludes the incidence of pulmonary embolism which is higher for the bilateral replacements

Aims

The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup.

Aims

It can be extremely challenging to determine whether to perform reimplantation in patients who have contradictory serum inflammatory markers and frozen section results. We investigated whether patients with a positive frozen section at reimplantation were at a higher risk of reinfection despite normal ESR and CRP.

1. The technique and results of arthroplasty of the metatarso-phalangeal joints for the grossly deformed forefoot are described. 2. The early results are very encouraging. 3. Attention is drawn to some of the complicating problems in rheumatoid arthritis, particularly the hazard of arteritis

An episode of hypotension is common during cemented joint replacement, and has been associated with circulatory collapse and sudden death. We studied the mechanism of hypotension in two groups of six dogs after simulated bilateral cemented arthroplasty. In one group, with no lavage, the insertion of cement and prosthesis was followed by severe hypotension, elevated pulmonary artery pressure, decreased systemic vascular resistance and a 21% reduction in cardiac output. In the other group, pulsatile intramedullary lavage was performed before the simulated arthroplasties. Hypotension was less, and although systemic vascular resistance decreased, the cardiac output did not change. The severity of the hypotension, the decrease in cardiac output and an increase in prostaglandin metabolites were related to the magnitude of pulmonary fat embolism. Pulsatile lavage prevents much of this fat embolism, and hence the decrease in cardiac output. The relatively mild hypotension after lavage was secondary to transient vasodilation, which may accentuate the hypotension caused by the decreased cardiac output due to a large embolic fat load. We make recommendations for the prevention and management of hypotension during cemented arthroplasty

Arthrodesis of the knee is a simple and safe operation that ensures stability and freedom from pain. But it is achieved at the expense of movement and occasionally of social acceptability. If arthroplasty is to be recommended, the advantages of arthrodesis must be retained, with the added bonus of a functional arc of movement

We report the general mortality rate after total knee replacement and identify independent predictors of survival. We studied 2428 patients: there were 1127 men (46%) and 1301 (54%) women with a mean age of 69.3 years (28 to 94). Patients were allocated a predicted life expectancy based on their age and gender. There were 223 deaths during the study period. This represented an overall survivorship of 99% (95% confidence interval (CI) 98 to 99) at one year, 90% (95% CI 89 to 92) at five years, and 84% (95% CI 82 to 86) at ten years. There was no difference in survival by gender. A greater mortality rate was associated with increasing age (p < 0.001), American Society of Anesthesiologists (ASA) grade (p < 0.001), smoking (p < 0.001), body mass index (BMI) <  20 kg/m. 2. (p < 0.001) and rheumatoid arthritis (p < 0.001). Multivariate modelling confirmed the independent effect of age, ASA grade, BMI, and rheumatoid disease on mortality. Based on the predicted average mortality, 114 patients were predicted to have died, whereas 217 actually died. This resulted in an overall excess standardised mortality ratio of 1.90. Patient mortality after TKR is predicted by their demographics: these could be used to assign an individual mortality risk after surgery

We report a case of spontaneous physeal growth arrest of the distal femur in a nine-year-old child with Ewing’s sarcoma of the proximal femur treated with chemotherapy and endoprosthetic replacement. Owing to the extent of disuse osteoporosis at the time of surgery, the entire intramedullary canal up to the distal femoral physis was filled with cement. Three years later, the femur remained at its pre-operative length of 19 cm. Pre-operative calculations of further growth failed to account for the growth arrest, and the initial expandable growing prosthesis inserted has been revised to a longer one in order to address the leg-length discrepancy. To our knowledge, this is the only reported case of distal femoral physeal growth arrest following cemented endoprosthetic replacement of the proximal femur

We performed 20 de la Caffiniere trapeziometacarpal arthroplasties for osteoarthritis occurring only at this joint and reviewed all patients after periods of up to ten years. Eighteen arthroplasties were satisfactory postoperatively, although all 20 patients had a satisfactory range of motion and only one experienced pain after surgery such that it impeded normal function. Failure occurred in two patients and was due to overreaming of the trapezium during surgery and a traumatic dislocation. A radiolucency between the prosthesis and bone was observed in one arthroplasty, although this patient was asymptomatic. We recommend arthroplasty using the de la Caffiniere prosthesis as a satisfactory method of treatment for the osteoarthritic trapeziometacarpal joint

The records of 107 patients with displaced subcaptial hip fractures treated by Thompson's femoral head replacements have been reviewed to determine the mortality and certain aspects of systemic morbidity. Comparison was made with a group, matched exactly for age and sex, in which intertrochanteric fractures were treated by nail-plate fixation. The patients treated by Thompson's arthroplasty were further subdivided into two groups: one in which methylacrylic cement was used, and one in which it was not used. We found no difference in the mortality of the patients undergoing replacement arthroplasty and nail-plate fixation. Similarly there was no difference in the incidence of cerebrovascular incidents and myocardial infarction after operation. There was a higher incidence of transient cardiac failure following Thompson's arthroplasty. Hypotension during the operation occurred irrespective of whether cement was used; nor was the use of cement associated with increased mortality. However, it seems that methylacrylic cement does contribute to the cardiac failure that may occur after Thompson's arthroplasty

1. The results of twenty-eight "hinge" arthroplasties of the knee are described. 2. Failure was most often due to breaking of the prosthesis. 3. The design of the prosthesis has been modified as a result of experience in cases of mechanical failure. 4. The results suggest that with the use of the modified hinge good results may be obtainable in three out of four cases

Forty hips, which had previously been the site of tuberculous or pyogenic arthritis and which had later developed a degenerative arthritis, were treated by low-friction arthroplasty some forty years after the original infection. The results suggest that, when healing of the primary infection has been followed by a long period of quiescence with acceptable function before the onset of degenerative change, the arthroplasty can be confidently expected to result in greatly improved function and that this improvement is long-lasting

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15° (0 to 35) and the mean range of flexion was 115° (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours

Arthroplasty of the hip using an interposed multi-layered cap of amniotic membrane is reported in 28 patients with tuberculous arthritis. The disease had been present from one to seven years, and five patients had multiple discharging sinuses. Follow-up was from 30 to 46 months. Amniotic tissue caused no inflammatory reaction, or obvious rejection, and 25 patients were free of symptoms, with a good range of movement and a stable joint. The three failures were caused by dislocation, fracture of the femoral neck and extra-articular bone formation respectively. Amniotic arthroplasty seems to be capable of providing a painless, mobile and stable joint in patients with tuberculosis of the hip

When the Oxford unicompartmental meniscal bearing arthroplasty is used in the lateral compartment of the knee, 10% of the bearings dislocate. A radiological review was carried out to establish if dislocation was related to surgical technique. The postoperative radiographs of 46 lateral unicompartmental arthroplasties were analysed. Five variables which related to the position and alignment of the components were measured. Dislocations occurred in six knees. Only one of the five variables, the proximal tibial varus angle, had a statistically significant relationship to dislocation. This variable quantifies the height of the lateral joint line. The mean proximal tibial varus angle for knees the bearings of which had dislocated was 9° and for those which had not it was 5°. In both groups it was greater than would be expected in the normal knee (3°). Our study suggests that a high proximal tibial varus angle is associated with dislocation. The surgical technique should be modified to account for this, with care being taken to avoid damage to or over-distraction of the lateral soft tissues

If conclusions are to be of any value they must be definite and one cannot draw definite conclusions from less than, say, fifty cases followed up for at least five years. However, few surgeons will ever see fifty patients requiring arthroplasty of the knee, let alone operate of them, even in five years. Accordingly, this account of a new approach to the problem of knee arthroplasty is submitted in the hope that other surgeons may care to try it and thereby learn, and thus be able to teach, tile modifications and improvements that all new techniques seem so surely to need

Thirty patients with chronic pyogenic or tuberculous arthritis of the hip treated by Girdlestone's excision arthroplasty were reviewed two to seven years after operation. There was marked or complete relief of pain in 29, control of infection in 27, squatting and sitting cross-legged was possible in 27, and 16 were able to stand on the operated limb. Overall results were good in 16, fair in nine, and poor in five. Tuberculous disease was not reactivated and the use of traction for 12 weeks and a weight-relieving caliper for 12 months after operation helped to reduce the shortening to an average of 3.8 centimetres. Excision arthroplasty is considered a sound operation to restore the ability to squat and sit cross-legged

We prepared a prosthesis for the replacement of the lumbar vertebrae of sheep, using apatite- and wollastonite-containing glass-ceramic. The material is stronger than human cortical bone and has the special feature of chemical bonding to bone. Ten sheep underwent replacement of L3 and L4 vertebrae, without bone grafting. The animals were killed at intervals from three months to 27 months after operation, and the interface between the prosthesis and bone was examined radiologically, histologically and crystallographically. Bone bonding with the prosthesis had occurred in half the implants. It took at least one year for bonding to be complete, but an apatite layer on the surface of the prosthesis was observed as early as three months after the operation, suggesting the possibility of much earlier bone bonding if more rigid fixation of the prosthesis had been provided