Aims. We aimed to investigate if the use of the largest possible cobalt-chromium head articulating with polyethylene acetabular inserts would increase the in vivo wear rate in total hip arthroplasty. Methods. In a single-blinded randomized controlled trial, 96 patients (43 females), at a median age of 63 years (interquartile range (IQR) 57 to 69), were allocated to receive either the largest possible modular femoral head (36 mm to 44 mm) in the thinnest possible insert or a standard 32 mm head. All patients received a vitamin E-doped cross-linked polyethylene insert and a cobalt-chromium head. The primary outcome was proximal head penetration measured with radiostereometric analysis (RSA) at two years. Secondary outcomes were volumetric wear, periacetabular radiolucencies, and patient-reported outcomes. Results. At two years, 44 patients in each group were available for RSA assessment. The median total two-year proximal head penetration was -0.02 mm (IQR -0.09 to 0.07; p = 0.548) for the largest possible head and -0.01 mm (IQR -0.07 to 0.10; p = 0.525) for 32 mm heads. Their difference was not statistically significant (p = 0.323). Neither group demonstrated a bedding-in period. The median steady-state volumetric wear rates were 6.1 mm. 3. /year (IQR -59 to 57) and 3.5 mm. 3. /year (-21 to 34) respectively, and did not differ between the groups (p = 0.848). There were no statistically significant differences in periacetabular radiolucencies or patient-reported outcomes. Conclusion. The use of the largest possible metal head did not increase vitamin E-doped cross-linked polyethylene wear compared with 32 mm heads at two years. Linear wear was negligible and volumetric wear rates were very low in both head size groups. There was a tendency towards higher values of volumetric wear in large heads that warrants longer-term evaluation before any definite conclusions about the association between head size and wear can be drawn. Cite this article: Bone Joint J 2021;103-B(7):1206–1214

Aims. Head-taper corrosion is a cause of failure in total hip arthroplasty (THA). Recent reports have described an increasing number of V40 taper failures with adverse local tissue reaction (ALTR). However, the real incidence of V40 taper damage and its cause remain unknown. The aim of this study was to evaluate the long-term incidence of ALTR in a consecutive series of THAs using a V40 taper and identify potentially related factors. Methods. Between January 2006 and June 2007, a total of 121 patients underwent THA using either an uncemented (Accolade I, made of Ti. 12. Mo. 6. Zr. 2. Fe; Stryker, USA) or a cemented (ABG II, made of cobalt-chrome-molybdenum (CoCrMo); Stryker) femoral component, both with a V40 taper (Stryker). Uncemented acetabular components (Trident; Stryker) with crosslinked polyethylene liners and CoCr femoral heads of 36 mm diameter were used in all patients. At a mean folllow-up of 10.8 years (SD 1.1), 94 patients (79%) were eligible for follow-up (six patients had already undergone a revision, 15 had died, and six were lost to follow-up). A total of 85 THAs in 80 patients (mean age 61 years (24 to 75); 47 (56%) were female) underwent clinical and radiological evaluation, including the measurement of whole blood levels of cobalt and chrome. Metal artifact reduction sequence MRI scans of the hip were performed in 71 patients. Results. A total of 20 ALTRs were identified on MRI, with an incidence of 26%. Patients with ALTR had significantly higher median Co levels compared with those without ALTR (2.96 μg/l (interquartile range (IQR) 1.35 to 4.98) vs 1.44 μg/l (IQR 0.79 to 2.5); p = 0.019). Radiological evidence of osteolysis was also significantly associated with ALTR (p = 0.014). Median Cr levels were not significantly higher in those with ALTR compared with those without one (0.97 μg/l (IQR 0.72 to 1.9) v 0.67 μg/l (IQR 0.5 to 1.19; p = 0.080). BMI, sex, age, type of femoral component, head length, the inclination of the acetabular component, and heterotopic ossification formation showed no significant relationship with ALTR. Conclusion. Due to the high incidence of local ALTR in our cohort after more than ten years postoperatively, we recommend regular follow-up investigation even in asymptomatic patients with V40 taper and metal heads. As cobalt levels correlate with ALTR occurrence, routine metal ion screening and consecutive MRI investigation upon elevation could be discussed. Cite this article: Bone Joint J 2022;104-B(7):852–858

Aims. Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. Methods. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation. Results. A total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure. Conclusion. The rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and an intact rotator cuff. There was no difference in the revision rate for HA according to bearing surface. Cite this article: Bone Joint J 2024;106-B(5):482–491

Aims. This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads. Methods. In all, six 28 mm and six 36 mm titanium stem-cobalt chrome head pairs with polyethylene sockets were tested in a novel instrumented hip simulator. Samples were tested using simulated gait data with incremental increasing loads to determine corrosion onset load and electrochemical activity. Half of each head size group were then cycled with simulated gait and the other half with gait compression only. Damage was measured by area and maximum linear wear depth. Results. Overall, 36 mm heads had lower corrosion onset load (p = 0.009) and change in open circuit potential (OCP) during simulated gait with (p = 0.006) and without joint movement (p = 0.004). Discontinuing gait’s joint movement decreased corrosion currents (p = 0.042); however, wear testing showed no significant effect of joint movement on taper damage. In addition, 36 mm heads had greater corrosion area (p = 0.050), but no significant difference was found for maximum linear wear depth (p = 0.155). Conclusion. Larger heads are more susceptible to taper corrosion; however, not due to frictional torque as hypothesized. An alternative hypothesis of taper flexural rigidity differential is proposed. Further studies are necessary to investigate the clinical significance and underlying mechanism of this finding. Cite this article: Bone Jt Open 2021;2(11):1004–1016

Aims

In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow.

Aims. The primary outcome was investigating differences in wear, as measured by femoral head penetration, between cross-linked vitamin E-diffused polyethylene (vE-PE) and cross-linked polyethylene (XLPE) acetabular component liners and between 32 and 36 mm head sizes at the ten-year follow-up. Secondary outcomes included acetabular component migration and patient-reported outcome measures (PROMs) such as the EuroQol five-dimension questionnaire, 36-Item Short-Form Health Survey, Harris Hip Score, and University of California, Los Angeles Activity Scale (UCLA). Methods. A single-blinded, multi-arm, 2 × 2 factorial randomized controlled trial was undertaken. Patients were recruited between May 2009 and April 2011. Radiostereometric analyses (RSAs) were performed from baseline to ten years. Of the 220 eligible patients, 116 underwent randomization, and 82 remained at the ten-year follow-up. Eligible patients were randomized into one of four interventions: vE-PE acetabular liner with either 32 or 36 mm femoral head, and XLPE acetabular liner with either 32 or 36 mm femoral head. Parameters were otherwise identical except for acetabular liner material and femoral head size. Results. A total of 116 patients participated, of whom 77 were male. The median ages of the vE-PE 32 mm and 36 mm groups were 65 (interquartile range (IQR) 57 to 67) and 63 years (IQR 56 to 66), respectively, and of the XLPE 32 mm and 36 mm groups were 64 (IQR 58 to 66) and 61 years (IQR 54 to 66), respectively. Mean total head penetration was significantly lower into vE-PE acetabular liner groups than into XLPE acetabular liner groups (-0.219 mm (95% confidence interval -0.348 to -0.090); p = 0.001). There were no differences in wear according to head size, acetabular component migration, or PROMs, except for UCLA. There were no cases of aseptic loosening or failures requiring revision at long-term follow-up. Conclusion. Significantly lower wear was observed in vE-PE acetabular liners than in XLPE acetabular liners. No difference in wear was observed between different head size or PROMs except for the UCLA at ten years. Cite this article: Bone Joint J 2023;105-B(10):1052–1059

Aims. The aim of this study was to evaluate fretting and corrosion in retrieved oxidized zirconium (OxZr; OXINIUM, Smith & Nephew, Memphis, Tennessee) femoral heads and compare the results with those from a matched cohort of cobalt-chromium (CoCr) femoral heads. Patients and Methods. A total of 28 OxZr femoral heads were retrieved during revision total hip arthroplasty (THA) and matched to 28 retrieved CoCr heads according to patient demographics. The mean age at index was 56 years (46 to 83) in the OxZr group and 70 years (46 to 92) in the CoCr group. Fretting and corrosion scores of the female taper of the heads were measured according to the modified Goldberg scoring method. Results. The OxZr-retrieved femoral heads showed significantly lower mean corrosion scores than the CoCr heads (1.3 (1 to 2.75) vs 2.1 (1 to 4); p < 0.01). Mean fretting scores were also significantly lower in the OxZr cohort when compared with the CoCr cohort (1.3 (1 to 2) vs 1.5 (1 to 2.25); p = 0.02). OxZr heads had more damage in the proximal region compared with the distal region of the head. Location had no impact on damage of CoCr heads. A trend towards increased corrosion in large heads was seen only in the CoCr heads, although this was not statistically significant. Conclusion. Retrieval analysis of OxZr femoral heads showed a decreased amount of fretting and corrosion compared with CoCr femoral heads. OxZr seems to be effective at reducing taper damage. Cite this article: Bone Joint J 2019;101-B:386–389

Aims. The most frequent indication for revision surgery in total hip arthroplasty (THA) is aseptic loosening. Aseptic loosening is associated with polyethylene liner wear, and wear may be reduced by using vitamin E-doped liners. The primary objective of this study was to compare proximal femoral head penetration into the liner between a) two cross-linked polyethylene (XLPE) liners (vitamin E-doped (vE-PE)) versus standard XLPE liners, and b) two modular femoral head diameters (32 mm and 36 mm). Methods. Patients scheduled for a THA were randomized to receive a vE-PE or XLPE liner with a 32 mm or 36 mm metal head (four intervention groups in a 2 × 2 factorial design). Head penetration and acetabular component migration were measured using radiostereometric analysis at baseline, three, 12, 24, and 60 months postoperatively. The Harris Hip Score, University of California, Los Angeles (UCLA) Activity Score, EuroQol five-dimension questionnaire (EQ-5D), and 36-Item Short-Form Health Survey questionnaire (SF-36) were assessed at baseline, three, 12, 36, and 60 months. Results. Of 220 screened patients, 127 were included in this study. In all, 116 received the allocated intervention, and 94 had their results analyzed at five years. Head penetration was similar between liner materials and head sizes at five years, vE-PE versus XLPE was -0.084 mm (95% confidence interval (CI) -0.173 to 0.005; p = 0.064), and 32 mm versus 36 mm was -0.020 mm (95% CI -0.110 to 0.071; p = 0.671), respectively. No differences were found in acetabular component migration or in the patient-reported outcome measures. Conclusion. No significant difference in head penetration was found at five years between vE-PE and XLPE liners, nor between 32 mm and 36 mm heads. Cite this article: Bone Joint J 2020;102-B(10):1303–1310

Large femoral heads have been used with increasing frequency over the last decade. The prime reason is likely the effect of large heads on stability. The larger head neck ratio, combined with the increased jump distance of larger heads result in a greater arc of impingement free motion, and greater resistance to dislocation in a provocative position. Multiple studies have demonstrated clear clinical efficacy in diminishing dislocation rates with the use of large femoral heads. With crosslinked polyethylene, wear has been shown to be equivalent between larger and smaller heads. However, the stability advantages of increasing diameter beyond 38 mm have not been clearly demonstrated. More importantly, recent data implicates large heads in the increasing prevalence of groin pain and psoas impingement. There are clear benefits with larger femoral head diameters, but the advantages of diameters beyond 38 mm have not yet been demonstrated clinically

Objectives. The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration. Methods. In total, 22 resected LHB tendons were classified into inflamed samples (n = 11) and non-inflamed samples (n = 11). Proliferation potential and specific marker gene expression of primary LHB-derived cell cultures were analyzed. Multipotentiality, including osteogenic, adipogenic, chondrogenic, and tenogenic differentiation potential of both groups were compared under respective lineage-specific culture conditions. Results. Inflammation does not seem to affect the proliferation rate of the isolated tendon-derived stem cells (TDSCs) and the tenogenic marker gene expression. Cells from both groups showed an equivalent osteogenic, adipogenic, chondrogenic and tenogenic differentiation potential in histology and real-time polymerase chain reaction (RT-PCR) analysis. Conclusion. These results suggest that the LHB tendon might be a suitable cell source for regenerative approaches, both in inflamed and non-inflamed states. The LHB with and without tendinitis has been characterized as a novel source of TDSCs, which might facilitate treatment of degeneration and induction of regeneration in shoulder surgery. Cite this article: J. Schmalzl, P. Plumhoff, F. Gilbert, F. Gohlke, C. Konrads, U. Brunner, F. Jakob, R. Ebert, A. F. Steinert. Tendon-derived stem cells from the long head of the biceps tendon: Inflammation does not affect the regenerative potential. Bone Joint Res 2019;8:414–424. DOI: 10.1302/2046-3758.89.BJR-2018-0214.R2

Aims. The purpose of this study was to identify the changes in untreated long head of the biceps brachii tendon (LHBT) after a rotator cuff tear and to evaluate the factors related to the changes. Methods. A cohort of 162 patients who underwent isolated supraspinatus with the preservation of LHBT was enrolled and evaluated. The cross-sectional area (CSA) of the LHBT on MRI was measured in the bicipital groove, and preoperative to postoperative difference was calculated at least 12 months postoperatively. Second, postoperative changes in the LHBT including intratendinous signal change, rupture, dislocation, or superior labral lesions were evaluated with seeking of factors that were correlated with the changes or newly developed lesions after rotator cuff repair. Results. The postoperative CSA (12.5 mm. 2. (SD 8.3) was significantly larger than preoperative CSA (11.5 mm. 2. (SD 7.5); p = 0.005). In total, 32 patients (19.8%) showed morphological changes in the untreated LHBT 24 months after rotator cuff repair. Univariate regression analysis revealed that the factor chiefly related to the change in LHBT status was an eccentric LHBT position within the groove found on preoperative MRI (p = 0.011). Multivariate analysis using logistic regression also revealed that an eccentric LHBT position was a factor related to postoperative change in untreated LHBTs (p = 0.011). Conclusion. The CSA of the LHBT inside the biceps groove increased after rotator cuff repair. The preoperative presence of an eccentrically positioned LHBT was associated with further changes of the tendon itself after rotator cuff repair. Cite this article: Bone Joint J 2020;102-B(9):1194–1199

Objectives. Modular junctions are ubiquitous in contemporary hip arthroplasty. The head-trunnion junction is implicated in the failure of large diameter metal-on-metal (MoM) hips which are the currently the topic of one the largest legal actions in the history of orthopaedics (estimated costs are stated to exceed $4 billion). Several factors are known to influence the strength of these press-fit modular connections. However, the influence of different head sizes has not previously been investigated. The aim of the study was to establish whether the choice of head size influences the initial strength of the trunnion-head connection. Materials and Methods. Ti-6Al-4V trunnions (n = 60) and two different sizes of cobalt-chromium (Co-Cr) heads (28 mm and 36 mm; 30 of each size) were used in the study. Three different levels of assembly force were considered: 4 kN; 5 kN; and 6 kN (n = 10 each). The strength of the press-fit connection was subsequently evaluated by measuring the pull-off force required to break the connection. The statistical differences in pull-off force were examined using a Kruskal–Wallis test and two-sample Mann–Whitney U test. Finite element and analytical models were developed to understand the reasons for the experimentally observed differences. Results. 36 mm diameter heads had significantly lower pull-off forces than 28 mm heads when impacted at 4 kN and 5 kN (p < 0.001; p < 0.001), but not at 6 kN (p = 0.21). Mean pull-off forces at 4 kN and 5 kN impaction forces were approximately 20% larger for 28 mm heads compared with 36 mm heads. Finite element and analytical models demonstrate that the differences in pull-off strength can be explained by differences in structural rigidity and the resulting interface pressures. Conclusion. This is the first study to show that 36 mm Co-Cr heads have up to 20% lower pull-off connection strength compared with 28 mm heads for equivalent assembly forces. This effect is likely to play a role in the high failure rates of large diameter MoM hips. Cite this article: A. R. MacLeod, N. P. T. Sullivan, M. R. Whitehouse, H. S. Gill. Large-diameter total hip arthroplasty modular heads require greater assembly forces for initial stability. Bone Joint Res 2016;5:338–346. DOI: 10.1302/2046-3758.58.BJR-2016-0044.R1

Objectives. Our primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age. Patients and Methods. A prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones. Results. Mean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02). Conclusion. Exeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups. Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019;8:275–287. DOI: 10.1302/2046-3758.86.BJR-2018-0300.R1

Aims. Modular dual-mobility constructs reduce the risk of dislocation after revision total hip arthroplasty (THA). However, questions about metal ions from the cobalt-chromium (CoCr) liner persist, and are particularly germane to patients being revised for adverse local tissue reactions (ALTR) to metal. We determined the early- to mid-term serum Co and Cr levels after modular dual-mobility components were used in revision and complex primary THAs, and specifically included patients revised for ALTR. Patients and Methods. Serum Co and Cr levels were measured prospectively in 24 patients with a modular dual-mobility construct and a ceramic femoral head. Patients with CoCr heads or contralateral THAs with CoCr heads were excluded. The mean age was 63 years (35 to 83), with 13 patients (54%) being female. The mean follow-up was four years (2 to 7). Indications for modular dual-mobility were prosthetic joint infection treated with two-stage exchange and subsequent reimplantation (n = 8), ALTR revision (n = 7), complex primary THA (n = 7), recurrent instability (n = 1), and periprosthetic femoral fracture (n = 1). The mean preoperative Co and Cr in patients revised for an ALTR were 29.7 μg/l (2 to 146) and 21.5 μg/l (1 to 113), respectively. Results. Mean Co and Cr levels were 0.30 μg/l and 0.76 μg/l, respectively, at the most recent follow-up. No patient had a Co level ≥ 1 μg/l. Only one patient had a Cr level ≥ 1 μg/l. That patient’s Cr level was 12 μg/l at 57 months after revision THA for ALTR (and decreased ten-fold from a preoperative Cr of 113 μg/l). Conclusion. At a mean of four years, no patient with a modular dual-mobility construct and ceramic femoral head had elevated Co levels, including seven patients revised specifically for ALTR. While further studies are required, we support the selective use of a modular dual-mobility construct in revision and complex primary THAs for patients at high risk for instability. Cite this article: Bone Joint J 2019;101-B(6 Supple B):57–61

Surgical access to the head of the radius is usually performed through a lateral approach. We present an alternative technique through a modified posterior approach which was developed following dissections of 22 human cadavers. An osteotomy of the supinator tuberosity was performed and reflected as a single unit with the attached annular ligament. Excellent exposure of the head of the radius was achieved, replacement of the head was undertaken and the osteotomy site repaired. The elbows were stable and had a full range of movement. The approach was then carried out on 13 patients for elective replacement of the head and was found to be safe and reproducible. In the patient group all osteotomies united, the elbows were stable and had an improved range of supination and pronation. There was no change in flexion and extension of the elbow. Complications included a haematoma and a reflex sympathetic dystrophy. The modified posterior approach provides excellent access to the head and neck of the radius, gives good stability of the elbow and allows early mobilisation of the joint

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis. Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them

1. At necropsy the arterial distribution within the head and neck of the femur was investigated by arteriographic injection in fifty-seven uninjured hips of mostly elderly subjects. 2. Before injection all vessels to the head except for one or more particular groups were divided. 3. The superior retinacular arteries were found to be the most important arterial supply to the head. Through the widely distributed branches of their lateral epiphysial vessels (superior capital) they supplied the superior, medial, central and usually the lateral parts of the head: through anastomoses they could also supply the anterior and posterior segments, the subfovea and the inferior sector, which receive separate contributions. Sometimes the inferior or the lateral connections were defective. 4. The arteries in the ligamentum teres were either absent or unimportant for the head in most subjects. Either the vessels in the ligament never reached the head or they supplied only a limited subfoveal zone. In only one out of sixteen specimens was the whole head injected through the vessels of the ligamentum teres. 5. The inferior retinacular arteries were found to be of subsidiary importance and generally supplied a variable infero-lateral part of the head, particularly posteriorly. In a small number there was an anastomotic supply to other parts of the head, but only in two out of sixteen specimens was nearly all the head injected through these vessels. 6. The regular anastomotic supply from the superior retinacular arteries to the subfovea and to the inferior part of the head was in curious contrast to the infrequent anastomotic filling of the lateral epiphysial arteries from the inferior retinacular or ligamentum teres arteries. 7. Vessels within the femoral neck sometimes supplied the lateral part of the head but never the medial three-quarters. 8. The neck of the femur received important branches from the superior retinacular arteries but only in a small number (15 per cent) was part of it entirely dependent on this supply

Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p < 0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications. In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes

Although alumina has been used in orthopaedic surgery since the 1970s, the long-term clinical results of zirconia have not been well documented in vivo. We studied hips with these two different ceramics during the same period and with a minimum follow-up of ten years. Because the size of the alumina and zirconia heads was different, hips with 32 mm alumina heads and those with 28 mm zirconia heads were compared with control hips with stainless-steel heads of the same size. Our aim was to compare the two ceramics. There was an increased linear rate of penetration of the femoral heads into the liner between years five and 12 for the zirconia and the stainless-steel groups. This was severe in the zirconia group (0.4 mm/year compared with 0.13 mm/year for the stainless-steel group). During the same 12-year period there was, however, no significant change in the rate of wear in the alumina group (0.07 mm/year). The mean wear at the most recent follow-up was 1360 mm. 3. for the 28 mm zirconia group, 683 mm. 3. for the 28 mm stainless-steel group, 755 mm. 3. for the 32 mm alumina group and 1314 mm. 3. for the 32 mm stainless-steel group. The monoclinic content rose on the surface of three zirconia heads which were retrieved at revision. This change was associated with an increase in the surface roughness. A change in the roundness with an increase in the sphericity deviation was also observed both in the articular and non-articular parts of the femoral heads. The increase in rate of wear in the zirconia group was only evident after eight years and may be linked to a long-term biodegradation of zirconia in vivo, associated with the altered roughness and roundness which was observed on the retrieved heads

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach

It has been suggested that the wear of ultra-high molecular weight polyethylene (UHMWPE) in total hip replacement is substantially reduced when the femoral head is ceramic rather than metal. However, studies of alumina and zirconia ceramic femoral heads on the penetration of an UHMWPE liner in vivo have given conflicting results. The purpose of this study was to examine the surface characteristics of 30 alumina and 24 zirconia ceramic femoral heads and to identify any phase transformation in the zirconia heads. We also studied the penetration rate of alumina and zirconia heads into contemporary UHMWPE liners. The alumina heads had been implanted for a mean of 11.3 years (8.1 to 16.2) and zirconia heads for a mean of 9.8 years (7.5 to 15). The mean surface roughness values of the explanted alumina heads (Ra 40.12 nm and Rpm 578.34 nm) were similar to those for the explanted zirconia heads (Ra 36.21 nm and Rpm 607.34 nm). The mean value of the monoclinic phase of two control zirconia heads was 1% (0.8% to 1.5%) and 1.2% (0.9% to 1.3%), respectively. The mean value of the monoclinic phase of 24 explanted zirconia heads was 7.3% (1% to 26%). In the alumina group, the mean linear penetration rate of the UMWPE liner was 0.10 mm/yr (0.09 to 0.12) in hips with low Ra and Rpm values (13.22 nm and 85.91 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.13 mm/yr (0.07 to 0.23) in hips with high Ra and Rpm values (198.72 nm and 1329 nm, respectively). This difference was significant (p = 0.041). In the zirconia head group, the mean linear penetration rate of the UHMWPE liner was 0.09 mm/yr (0.07 to 0.14) in hips with low Ra and Rpm values (12.78 nm and 92.99 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.12 mm/yr (0.08 to 0.22) in hips with high Ra and Rpm values (199.21 nm and 1381 nm, respectively). This difference was significant (p = 0.039). The explanted zirconia heads which had a minimal phase transformation had similar surface roughness and a similar penetration rate of UHMWPE liner as the explanted alumina head

We investigated the incidence of soft-tissue lesions after small head metal-on-metal total hip replacement (MoM THR). Between December 1993 and May 1999, 149 patients (195 hips) underwent primary cementless MoM THR. During the follow-up period, three patients (five THRs) died and eight patients (14 THRs) were lost to follow-up. We requested that all patients undergo CT evaluation. After exclusion of five patients (six THRs) who had undergone a revision procedure, and 22 (28 THRs) who were unwilling to take part in this study, 111 patients (142 THRs) were evaluated. There were 63 men (88 THRs) and 48 women (54 THRs) with a mean age of 45.7 years (37 to 56) at the time of surgery. The mean follow-up was 15.4 years (13 to 19). A soft-tissue lesion was defined as an abnormal peri-prosthetic collection of fluid, solid lesion or asymmetrical soft-tissue mass. At final follow-up, soft-tissue lesions were found in relation to 28 THRs (19.7%), including 25 solid and three cystic lesions. They were found in 20 men and eight women; 26 lesions were asymptomatic and two were symptomatic. The mean maximal diameter of the soft-tissue lesion was 42.3 mm (17 to 135). The relatively high rate of soft-tissue lesions observed with small head MoM THR remains a concern. Cite this article: Bone Joint J 2014;96-B:1594–9

We describe a patient with a Mason type-III fracture of the head of the radius associated with traumatic dislocation of the elbow. The radial head was intact throughout its circumference despite being completely detached from the shaft and devoid of any soft-tissue attachments. Severe comminution of the radial neck prevented reconstruction by internal fixation and precluded prosthetic replacement of the head. The head was fixed to the shaft with a tricortical iliac-crest bone graft which replaced the neck. Two years later, the patient had a stable elbow with flexion from 10° to 130°. Radiologically, the head of the radius appeared to be viable and the bone graft had incorporated

Objectives. Screw plugs have been reported to increase the fatigue strength of stainless steel locking plates. The objective of this study was to examine and compare this effect between stainless steel and titanium locking plates. Methods. Custom-designed locking plates with identical structures were fabricated from stainless steel and a titanium alloy. Three types of plates were compared: type I unplugged plates; type II plugged plates with a 4 Nm torque; and type III plugged plates with a 12 Nm torque. The stiffness, yield strength, and fatigue strength of the plates were investigated through a four-point bending test. Failure analyses were performed subsequently. Results. For stainless steel, type II and type III plates had significantly higher fatigue strength than type I plates. For titanium, there were no significant differences between the fatigue strengths of the three types of plates. Failure analyses showed local plastic deformations at the threads of screw plugs in type II and type III stainless steel plates but not in titanium plates. Conclusion. The screw plugs could increase the fatigue strength of stainless steel plates but not of titanium plates. Therefore, leaving screw holes open around fracture sites is recommended in titanium plates. Cite this article: L-W. Hung, C-K. Chao, J-R. Huang, J. Lin. Screw head plugs increase the fatigue strength of stainless steel, but not of titanium, locking plates. Bone Joint Res 2018;7:629–635. DOI: 10.1302/2046-3758.712.BJR-2018-0083.R1

We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation. . From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (. sd. ) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, . sd. 5) were recruited after a mean follow-up of 50 months (36 to 64). . The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without. . Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA. Cite this article: Bone Joint J 2015;97-B:1481–7

The treatment of a chronic posterior dislocation of the shoulder is often determined by the size of the associated impression fracture of the humeral head. Our hypothesis was that patients with a chronic unreduced posterior dislocation of the shoulder and a defect in the humeral head involving between 25% to 50% of the articular surface, would do better if reconstructed with an allograft from the femoral head rather than treated by a non-anatomical reconstruction. We reviewed ten men and three women with a mean age of 42 years (36 to 51) at a mean follow-up of 54 months (41 to 64) who had this procedure. At follow-up, nine had no pain or restriction of activities of daily living. Their mean Constant-Murley shoulder score was 86.8 (43 to 98). No patient had symptoms of instability of the shoulder. Reconstruction of the defect in the humeral head with an allograft provides good pain relief, stability and function for patients with a locked, chronic posterior dislocation where the defect involves between 25% and 50% of the circumference of the articular surface

We have reviewed 70 patients with bilateral simultaneous total hip arthroplasties to determine the rate of failure and to compare polyethylene wear and osteolysis between an implant with a cobalt-chrome head and Hylamer liner with that of a zirconia head and Hylamer liner. The mean thickness of the polyethylene liner was 11.0 mm (8.8 to 12.2) in the hip with a zirconia head and 10.7 mm (8.8 to 12.2) in that with a cobalt-chrome head. At follow-up at 6.4 years no acetabular or femoral component had been revised for aseptic loosening and no acetabular or femoral component was loose according to radiological criteria in both the cemented and cementless groups. The mean rate of linear wear and annual wear rate were highest in the 22 mm zirconia femoral head (1.25 mm (SD 1.05) and 0.21 mm (SD 0.18), respectively) and lowest in the 22 mm cobalt-chrome femoral head (0.70 mm (SD 0.39) and 0.12 mm (SD 0.07), respectively). The mean volumetric wear was highest in the 28 mm zirconia femoral head (730.79 mm. 3. ) and lowest in the 22 mm cobalt-chrome femoral head (264.67 mm. 3. ), but if the results were compared by size of the femoral head and type of material there was no statistical difference (p > 0.05). Sequential measurements of annual wear showed that the zirconia femoral head had a relatively higher rate of penetration than the cobalt-chrome head over the first three years; thereafter the rate of wear was reduced and compared favourably with that of cobalt-chrome heads. There was a statistically significant relationship between the wear of the polyethylene liner and the age of the patient, male gender and the degree of abduction angle of the cup, but not diagnosis, weight, hip score, range of movement, or amount of anteversion. Osteolysis was identified on both sides of the acetabulum in six patients (9%). Of 12 hips with acetabular osteolysis, six had a 28 mm cobalt-chrome femoral head and the remaining six a 28 mm zirconia head. Osteolysis was observed in zones 1A and 7A of the femur in two hips (3%) with a 28 mm zirconia head (cemented hip) and in four (6%) with a 28 mm cobalt-chrome femoral head (cementless hip). Our findings suggest that although the performance of a zirconia femoral head with a Hylamer liner was not statistically different from that of a cobalt-chrome femoral head and Hylamer liner, there was a trend for the zirconia head to be worse than the cobalt-chrome femoral head

This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed

1. Full recovery after fracture of the head of the radius in children may be expected in cases with tilting of the radial head from 30 to 60 degrees, whether treated by early manipulative or by operative reduction. 2. Manipulative reduction is facilitated by knowledge of the direction of displacement and tilting of the radial head, which can be determined by the study of appropriate radiographs. 3. When the upper radial epiphysis is completely displaced from the shaft, some permanent loss of movement is to be anticipated even when accurate reduction has been secured by operation. Early fusion and some deformity of the radial head are also to be expected. This is not surprising in view of the risk to the blood supply of the displaced head, particularly in those cases treated by operative reduction

We studied the arterial anatomy and the effect of four-part fractures on the vascularity of the humeral head, using barium sulphate perfusion of 16 cadaver shoulders. The main arterial supply to the humeral head was via the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There were significant intraosseous anastomoses between the arcuate artery and: 1) the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus; 2) metaphyseal vessels; and 3) the vessels of the greater and lesser tuberosities. Simulated four-part fractures prevented the perfusion of the humeral head in most cases. If, however, the head fragment extends distally below the articular surface medially, some perfusion of the head persists by the posteromedial vessels. These vessels are important in the management of comminuted fractures of the proximal humerus

We report two cases of surface deterioration of a zirconia ceramic femoral head associated with phase transformation after total hip arthroplasty. One head was retrieved at revision due to recurrent dislocation after six years and the other because of failure of the locking mechanism of the polyethylene liner after three years. The monoclinic content of the zirconia ceramics rose from 1% to about 30% on the surface of the heads. SEM revealed numerous craters indicating extraction of the zirconia ceramics at the surface. Surface roughness increased from an initial value of 0.006 3m up to 0.12 3m. This is the first report to show that phase transformation of zirconia ceramics causes deterioration of the surface roughness of the head in vivo after total hip arthroplasty

The articular surface of the humeral head is usually described as facing posteromedially, making an angle of between 16 degrees and 35 degrees with the transepicondylar plane. At hemiarthroplasty the articular surface also appears to be offset posteriorly with respect to the humeral shaft. Coracoid impingement may occur if this offset is not accommodated. An analysis was made of 29 cadaveric humeri using an industrial co-ordinate measuring machine. The position of the centre of the head was defined with respect to the humeral shaft and transepicondylar plane. The humeral articular surface was found to be retroverted by 21.4 degrees and its centre offset posteriorly by 4.7 mm. Previous interpretation of retroversion did not take into account the posterior displacement, and this may be of importance in improving future prosthetic design

We undertook a study on eight arms from fresh cadavers to define the clinical usefulness of the lesser sigmoid notch as a landmark when reconstructing the length of the neck of the radius in replacement of the head with a prosthesis. The head was resected and its height measured, along with several control measurements. This was compared with in situ measurements from the stump of the neck to the proximal edge of the lesser sigmoid notch of the ulna. All the measurements were performed three times by three observers acting independently. The results were highly reproducible with intra- and interclass correlations of > 0.99. The mean difference between the measurement on the excised head and the distance from the stump of the neck and the lesser sigmoid notch was −0.02 mm (−1.24 to +0.97). This difference was not statistically significant (p = 0.78). The proximal edge of the lesser sigmoid notch provides a reliable landmark for positioning a replacement of the radial head and may have clinical application

1. Sixty-five cases of medial fracture of the femoral neck treated by substitution of the head by an acrylic prosthesis have been studied. 2. In general, the long-term clinical results of prosthetic arthroplasty after fresh fractures have been disappointing. The method has given slightly better results in the treatment of old fractures. 3. In view of the almost perfect results obtained after successful Smith-Petersen nailing in the presence of an adequate blood supply to the femoral head, it seems unjustifiable to abandon this principle for immediate substitution with an acrylic femoral head. Nevertheless it is believed that an arthroplasty of this type is justified in fractures seen late, and in fresh subcapital fractures when the fracture is irreducible. If a prosthesis is to be used, more protection for the stump of the neck against the strain of weight bearing is essential; a simple head prosthesis is inadequate, and a head with either a neck extension or an intramedullary prolongation may give better results

1. Radiological criteria in the diagnosis of congenital dislocation of the head of the radius are suggested. 2. Some of the radiographic features described as characteristic of congenital dislocation of the head of the radius may be found also in post-traumatic dislocation of the radial head

We investigated the function of biceps in 18 patients (19 shoulders) with lesions of the rotator cuff. Their mean age was 59 years. Another series of 18 patients (19 shoulders) with normal rotator cuffs as seen on MRI acted as a control group. Their mean age was 55 years. A brace was used to maintain contraction of biceps during elevation. Anteroposterior radiographs were obtained with the arm elevated at 0°, 45° and 90° with and without contraction of biceps. The distance between the centre of the head of the humerus and the glenoid was compared in the two groups. We found that in the group with tears there was significantly greater proximal migration of the head of the humerus at 0° and 45° of elevation without contraction of biceps but depression of the head of the humerus at 0°, 45° and 90° when biceps was functioning. We conclude that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head

Aims. The aim of this study was to assess hypertrophy of the extra-articular tendon of the long head of biceps (LHB) in patients with a rotator cuff tear. Patients and Methods. The study involved 638 shoulders in 334 patients (175 men, 159 women, mean age 62.6 years; 25 to 81) with unilateral symptomatic rotator cuff tears. The cross-sectional area (CSA) of the LHB tendon in the bicipital groove was measured pre-operatively in both shoulders using ultrasound. There were 154 asymptomatic rotator cuff tears in the contralateral shoulder. Comparisons were made between those with a symptomatic tear, an asymptomatic tear and those with no rotator cuff tear. In the affected shoulders, the CSAs were compared in relation to the location and size of the rotator cuff tear. . Results. The mean CSA was 21.0 mm. 2 . (4 to 71) in those with a symptomatic rotator cuff tear, 19.9 mm. 2. (4 to 75) in those with an asymptomatic rotator cuff tear and 14.1 mm. 2 . (5 to 43) in those with no rotator cuff tear. The mean CSA in patients with both symptomatic and asymptomatic rotator cuff tears was significantly larger than in those with no rotator cuff tear (p < 0.001). In the affected shoulders, there were significant differences between patients with more than a medium sized posterosuperior cuff tear and those with an antero-superior cuff tear. . Conclusion . Regardless of the symptoms, there was significant hypertrophy of the extra-articular LHB tendon in patients with a rotator cuff tear. The values were significantly related to the size of the tear. Cite this article: Bone Joint J 2017;99-B:806–11

A 59-year-old woman with calcific tendinitis in her right shoulder underwent extracorporeal shock-wave lithotripsy. Three years and four months later she presented with osteonecrosis of the head of the right humerus. It is known that shock waves in patients with urological disorders can damage blood vessels. A possible reason for the development of osteonecrosis in this patient may have been damage to the blood supply of the head of the humerus

We measured torsion of the humeral head in 38 patients (40 shoulders) with recurrent anterior dislocation of the shoulder (RADS) and in 40 normal subjects. We found a reduced mean retroversion in the patients with RADS at 4.3 +/- 10.56 degrees (17 degrees anteversion to 32 degrees retroversion) as compared with 16.1 +/- 11.07 degrees in the control group (0 degrees to 49 degrees) (p = 0.0001). There was anteversion in 11 of the 40 shoulders in the RADS group (27.5%) and in none of the control group. The first dislocation had occurred after minimal force in 18 of 25 patients with less than 10 degrees retroversion, but in only three of 15 with over 10 degrees retroversion. We conclude that decreased retroversion of the humeral head is often associated with RADS and with first dislocation of the shoulder caused by minimal force

Ninety-five patients with steroid-induced avascular necrosis of bone have been personally treated by the author. Of these, eighteen had a lesion of the head of the humerus, on one or both sides. The conditions for which the steroids were given included post-transplantation, lupus erythematosus, glomerulonephritis and asthma. The characteristic lesion began as a subchondral osteolytic area which frequently progressed to collapse. The articular cartilage divided from the subchondral bone, either becoming detached as a free cap or at a later stage reattaching. In some cases the lesion was minimal and the symptoms were slight. Conservative treatment has consisted of pendulum exercises and avoidance of abduction, particularly against resistance. In fourteen patients this led to satisfactory function with only intermittent symptoms. Four patients required replacement of five humeral heads with Neer's prostheses. After one to seven years the results of all five were classified as excellent in terms of absence of symptoms and a free range of movement

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

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (. sd. 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation. Cite this article: Bone Joint J 2013;95-B:1538–43

The results of excision of the head of the radius in forty-four elbows affected by rheumatoid arthritis are presented. Relief of pain was obtained in 90 per cent and an increase in the range of flexion and extension was seen in 70 per cent. Involvement of the humero-ulnar joint seen radiologically is no contra-indication to the operation; simple excision of the radial head often gives gratifying results; In our experience the relief of pain and increased range of movement have greatly reduced the need for total replacement arthroplasty

Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared

1. Two cases of an unrecognised congenital defect of the humeral head are described and the cause is discussed. 2. Only six cases with similar radiographic appearances could be collected from the literature. In most of these cases other skeletal deformities were present, whereas in those now reported only the shoulder was affected. 3. Examination of radiographs suggests that the main deformity consists of lack of development of the capital epiphysis of the humerus. 4. Consideration of the cases, together with experimental data from the studies of Fell and Canti, suggests that the time in development at which the fault occurred was the presumptive joint stage, just when the articular rudiments had separated. 5. A "nociferous agent," acting only for a limited period, and only on certain tissues, is postulated. 6. It is suggested that the defects recorded should be recognised as a group of congenital deformities of the shoulder joint

We report eight patients with prominent cystic changes in the head of the fibula. Seven of these had osteoarthritis of the adjacent knee, and five had evidence of local deposition of calcium pyrophosphate dihydrate crystals. A radiographic survey of 470 knees in 254 patients with osteoarthritis suggested that such cysts are rare, but should be considered in the differential diagnosis of such changes before expensive or invasive investigations are performed

Eighteen patients with marginal depressed or comminuted fractures of the head of the radius, nine of whom had an associated posterior dislocation of the elbow, had a Silastic replacement carried out shortly after injury. After an average follow-up of twenty-six months satisfactory clinical results were observed in seventeen cases; three prostheses broke. The prosthesis has been particularly effective in the group with an associated posterior dislocation of the elbow

I. Five cases of dislocation of the head of the radius associated with fracture of the upper end of the ulna in children are reported. It is important that fractures of the upper end of the ulna, especially those with some varus deformity in children, should arouse suspicion of the possible co-existence of a dislocation of the head of the radius. 2. The association of the injury to the elbow with a fracture of the lower end of the radius and ulna in three of our cases indicates the necessity for keeping in mind the possibility of this combination. 3. Closed reduction seems to be the best method of treatment. 4. Our five cases were seen during a period ofonly three years. We therefore believe that this injury is not as unusual as appears from the literature

We compared a modular neck system with a non-modular system in a cementless anatomical total hip replacement (THR). Each group consisted of 74 hips with developmental hip dysplasia. Both groups had the same cementless acetabular component and the same articulation, which consisted of a conventional polyethylene liner and a 28 mm alumina head. The mean follow-up was 14.5 years (13 to 15), at which point there were significant differences in the mean total Harris hip score (modular/non-modular: 98.6 (64 to 100)/93.8 (68 to 100)), the mean range of abduction (32° (15° to 40°)/28 (0° to 40°)), use of a 10° elevated liner (31%/100%), the incidence of osteolysis (27%/79.7%) and the incidence of equal leg lengths (≥ 6 mm, 92%/61%). There was no disassociation or fracture of the modular neck. The modular system reduces the need for an elevated liner, thereby reducing the incidence of osteolysis. It gives a better range of movement and allows the surgeon to make an accurate adjustment of leg length

This study compared the effect of a computer-assisted and a traditional surgical technique on the kinematics of the glenohumeral joint during passive abduction after hemiarthroplasty of the shoulder for the treatment of fractures. We used seven pairs of fresh-frozen cadaver shoulders to create simulated four-part fractures of the proximal humerus, which were then reconstructed with hemiarthroplasty and reattachment of the tuberosities. The specimens were randomised, so that one from each pair was repaired using the computer-assisted technique, whereas a traditional hemiarthroplasty without navigation was performed in the contralateral shoulder. Kinematic data were obtained using an electromagnetic tracking device. The traditional technique resulted in posterior and inferior translation of the humeral head. No statistical differences were observed before or after computer-assisted surgery. Although it requires further improvement, the computer-assisted approach appears to allow glenohumeral kinematics to more closely replicate those of the native joint, potentially improving the function of the shoulder and extending the longevity of the prosthesis

1. Three cases of fracture of the neck of the radius with medial displacement of the head are described. 2. It is proposed that such injuries be classified into two types: 1) displacement of the radial head without dislocation of the elbow; and 2) displacement during posterior dislocation of the elbow

The longitudinal arch between the heel and the forefoot and the transverse arch between the first and fifth metatarsal heads, absorb shock, energy and force. A device to measure plantar pressure was used in 66 normal healthy subjects and in 294 patients with various types of foot disorder. Only 22 (3%) of a total of 720 feet, had a dynamic metatarsal arch during the stance phase of walking, and all had known abnormality. Our findings show that there is no distal transverse metatarsal arch during the stance phase. This is important for the classification and description of disorders of the foot

We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an anatomical prosthesis for the humeral head and in 18 (group B) an implant designed for fractures. When followed up at a mean of 29.3 months after surgery the overall Constant score was 51.9 points; in group A it was 51.5 and in group B 52.4 points. The subjective satisfaction of the patients was assessed using a numerical rating scale and was similar in both groups. In group A complete healing of the tuberosities was found in 29% and 50% in group B. Partial integration was seen in 29% of group A and in only one patient in group B, while resorption was noted in 43% of group A and 44% of group B. The functional outcome was significantly better in patients with complete or partial healing of the tuberosities (p = 0.022). The specific trauma prosthesis did not lead to better healing of the tuberosities. The difference in clinical outcome obtained by the two designs did not reach statistical significance

We have examined 167 patients who had a hemiarthroplasty for three- and four-part fractures and fracture-dislocations of the head of the humerus in a multicentre study involving 12 Austrian hospitals. All patients were followed for more than a year. Anatomical healing of the tuberosity significantly influenced the outcome as measured by the Constant score and subjective patient satisfaction. With regard to pain, the outcome was generally satisfactory but only 41.9% of patients were able to flex the shoulder above 90°. The age of the patient and the type of prosthesis significantly influenced the healing of the tuberosity, but bone grafting did not. Achievement of healing of the tuberosity was inferior in institutions at which less than 15 hemiarthroplasties had been performed (Mann-Witney U test, p = 0.0001)

The vertical-centre-anterior margin (VCA) angle quantifies the anterior cover of the femoral head. However, when the femoral head is deformed it may be difficult to identify its centre. We have therefore created a new index, the anterior acetabular head index (AAHI) which is measured on the false-profile radiograph. We measured the VCA and AAHI angles in 312 hips in which the centre-edge angle was > 25°. There were 250 patients, 86 men and 164 women, whose ages ranged from 20 to 65 years. The mean AAHI was 84.1% (81.7% in women and 88.5% in men). There was a correlation between the AAHI and VCA angles. Our data suggest that the AAHI is useful in the evaluation of anterior acetabular cover and that it is higher in men than in women

A quantitative study of the vascularity and a qualitative study of the remodelling of the calcified cartilage and subchondral bone end-plate of adult human femoral and humeral heads were performed with respect to age. In the femoral head the number of vessels per unit area was found to fall 20% from adolescence until the seventh decade and in the humeral head 15% until the sixth decade. Thereafter an increase was noted in the femur but none in the humerus. More vessels were present at all ages in the more loaded areas of the articular surfaces: 25% more for the femur and 15% more for the humerus. The degree of active remodelling by endochondral ossification declined 50% from adolescence until the seventh decade in the femoral head, and 30% until the sixth decade in the humeral head, rising thereafter to levels comparable to those found at young ages. More remodeling was noted in the more loaded areas at all ages

Four patients who had injured the lower end of the humerus in childhood with resulting cubitus varus developed recurrent posterior dislocation of the head of the radius after further injury to the elbow. Dislocation occurred when the forearm was supinated and spontaneous reduction took place on pronation. At operation the lateral ligament complex was seen to be lax and elongated. After tightening of the ligament and with a supracondylar osteotomy of the humerus to correct the cubitus varus the recurrent dislocation was eliminated

1. Fifty-eight adult patients who had been treated for radial head fractures by excision of the head of the radius have been reviewed at periods varying between two and nineteen years after operation. 2. Symptoms referable to the inferior radio-ulnar joint were present in half of the patients and the mechanisms of the disorder in these patients are discussed in the light of a radiographic study. 3. We feel it justifiable to conclude from our observations that this complication of surgical treatment of radial head fractures deserves greater attention than has been given to it in the past, and that it is of sufficient importance to be taken into consideration when planning the management of these fractures, especially the less severe injuries. 4. Prosthetic replacement of the proximal end of the radius is the logical and, indeed, the only way in which the distal radio-ulnar joint subluxation can be avoided, but no clearly defined indications for the routine use of a prosthesis as a primary procedure can be suggested on the basis of this investigation

We undertook a prospective MRI study to measure the retroversion of the humeral head in 33 consecutive infants with a mean age of 1 year 10 months (3 months to 7 years 4 months) who had an obstetric brachial plexus lesion (OBPL). According to a standardised MRI protocol both shoulders and humeral condyles were examined and the shape of the glenoid and humeral retroversion determined. The mean humeral retroversion of the affected shoulder was significantly increased compared with the normal contralateral side (−28.4 ± 12.5° v −21.5 ± 15.1°, p = 0.02). This increase was found only in the children over the age of 12 months. In this group humeral retroversion was −29.9 ± 12.9° compared with −19.6 ± 15.6° in the normal shoulder (p = 0.009), giving a mean difference of 10.3° (95% confidence interval 3.3 to 17.3). This finding is of importance when considering the operative treatment for subluxation of the shoulder in children with an OBPL

1. Three cases of anterior dislocation of the head of the radius associated with an undisplaced fracture of the olecranon are described. 2. A combination of pronation of the forearm and hyperextension of the elbow is suggested as a possible mechanism

1. Sixteen injected specimens of human femoral heads and necks, in which a nail or screw had been inserted, were examined. 2. The possibility exists that the fixing agent may interfere with the blood supply of the femoral head. The likelihood of this occurrence is not great. 3. The position of the fixing agent in which vascular damage is least likely is the central area or "neutral zone" of the femoral neck and head

This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001). It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign

We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both

Implantation of a large-diameter femoral head prosthesis with a metal-on-metal bearing surface reduces the risk of dislocation, increases the range of movement, minimises the risk of impingement and, in theory, results in little wear.

Between February 2004 and March 2007 we implanted 100 consecutive total hip replacements with a metal-on-metal bearing and a large femoral head into 92 patients. There were 51 men and 41 women with a mean age of 50 years (18 to 70) at the time of surgery.

Outcome was assessed using the Western Ontario McMaster University osteoarthritis index and the Harris hip score as well as the Devane activity score. These all improved significantly (p < 0.0001). At the last follow-up there were no cases of dislocation, no impingement, a good range of movement and no osteolysis, but seven revisions, two for infection and five for aseptic loosening. The probability of groin pain increased if the other acetabular component inclination exceeded 50° (p = 0.0007). At 4.8 years of follow-up, the projected survival of the Durom acetabular component, with revision for any reason, was 92.4% (sd 2.8) (95% confidence interval 89.6 to 95.2).

The design of the component made it difficult both to orientate and seat, which when combined with a poor porous coating, produced unpredictable fixation and a low survival at five years.

1. A radiological study of the acromio-humcral interval in sixty normal shoulders and in fifty-nine shoulders with known tears of the rotator cuff is reported.

2. The normal acromio-humeral interval was found to be seven to fourteen millimetres, a range that is consistent with previous observations.

3. Narrowing of this interval is a frequent concomitant of a tear of the rotator cuff.

4. An interval of five millimetres or less should be considered compatible with a tear of the rotator cuff until proven otherwise.

5. An explanation of the pathomechanics of the observation has been proposed.

We have compared different types of intertrochanteric osteotomy for avascular of necrosis of the hip and evaluated their performance in the light of improving outcome after total hip arthroplasty (THA). During a period of 14 years we performed 63 flexion osteotomies (partly combined with varus or valgus displacement), 29 rotational osteotomies, 13 varus osteotomies, eight medialising osteotomies and two extension osteotomies. The mean period of follow-up for all 115 operations was 7.3 years (maximum 24.6).

At follow-up, 27 of 29 patients with a rotational osteotomy had already undergone a THA, compared with 36 of 63 after flexion osteotomy. A high incidence of complications (55.2%) was seen early after rotational osteotomy, compared with 17.5% after flexion osteotomy.

For all osteotomies there was a high correlation between the size of the necrotic area and the incidence of failure, which also correlated with the preoperative Ficat and Steinberg stages. Using Kaplan-Meier survivorship analysis, Sugioka’s rotational osteotomy showed a survival probability after five years of 0.26 (95% confidence interval 0.49 to 0.14), and after ten years of 0.15 (CI 0.36 to 0.06). The survival probability for flexion osteotomy was 0.70 (CI 0.83 to 0.59) after five years and 0.50 (CI 0.65 to 0.38) after ten years. The subgroup of flexion osteotomy with a necrotic sector of less than 180° achieved the best survival probability of 0.90 (CI 1.00 to 0.80) after five years and 0.61 (CI 0.84 to 0.45) after ten years.

The indications for intertrochanteric osteotomy for avascular necrosis of the hip have to be addressed critically. Even flexion osteotomy in cases with small areas of necrosis provides only temporary benefit. Rotational osteotomy was associated with a high incidence of complications.

We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years).

All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method.

Aims

This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures.

We have studied the histological appearances of forty femoral heads with idiopathic avascular necrosis. The characteristic histopathological changes of recurrent necrosis were present in 83 per cent. Recurrent necrosis occurred widely after revascularisation had progressed as far as the subchondral zone. The aetiology of idiopathic avascular necrosis of the femoral head may be a chronic condition which produces repeated infarction. The deformation and incomplete revascularisation of the femoral head may be due to repeated episodes of infarction as well as to mechanical factors related to weight-bearing.

The results of thirty synovectomies of the elbow for rheumatoid arthritis are reported. Satisfactory relief of pain was obtained in twenty-seven elbows and the range of movement was improved in twenty-one. The classical operation includes excision of the radial head but in this series approximately half the radial heads were conserved with comparable results. The results of synovectomy do not significantly deteriorate with time up to ten years and the operation can be done with good results, especially in respect of relief of pain, even in elbows with relatively advanced rheumatoid disease. Radiographic assessment is not of much help in evaluating the results of the operation, but is essential in selection of elbows for synovectomy.

We studied the risk of recurrent dislocation in 121 primary and 39 revision Charnley or Charnley hybrid total hip arthroplasties which had been treated for a primary dislocation between 1979 and 1995. Only 35% of these hips had no further dislocation or a revision for instability within one year. The rates of survival gradually declined with time or if a second, third or fourth dislocation occurred. The risk of recurrence was greater in men, but was not related to age, diagnosis, time of the first dislocation or whether the index operation had been a primary or a revision procedure.

Operative treatment included 15 reoperations leaving intact components, 50 revisions, and permanent removal of the femoral stem in seven patients. The operation was successful in four patients with reoperations and in 36 who had an exchange procedure within two years. Treatment was successful in 35 of 49 hips in which it was possible to correct a technical error compared with 5 out of 16 hips in which malposition of the components was not seen (p = 0.007).

1. Two children suffering from Gaucher's disease, who developed changes in the femoral head typical of Perthes' disease, are reported. Similar changes have been recorded in the literature in seventeen children under the age of fifteen years.

2. The possible factors giving rise to the bone changes are discussed and it is considered that they result from aseptic necrosis. Splenectomy does not appear to hasten the development of bone changes in this disease.

3. In one of the patients, the blood Wassermann reaction was positive, but syphilis was not thought to play any part in the production of the bone changes.

We describe three prostheses with cemented titanium-alloy stems and Al₂O₃ ceramic femoral heads which had to be revised after a mean period of implantation of 78 months. In each case, the neck of the prosthesis had been so severely worn that the profile was elliptical rather than circular. There was severe metallosis of the periprosthetic tissues. Metal particles isolated from the tissues were approximately one nanometre in size and the ratios of titanium, aluminium and vanadium in the particles were the same as in the original alloy. Histologically, the high concentration of metal particles masked the presence of high-density polyethylene (HDP) debris, but again particles about one nanometre in size were isolated from the tissues. The severe necrobiosis and necrosis noted were consistent with other reports of the presence of extensive wear particles in periprosthetic tissues. Wear is presumed to have occurred as a result of mismatch between the shape or size of the taper cone and the femoral head, or to changes in the geometry of loading due to migration of the cup. To facilitate early intervention, patients with this design of prosthesis should be monitored radiologically.

Aims. This study aimed to define the histopathology of degenerated humeral head cartilage and synovial inflammation of the glenohumeral joint in patients with omarthrosis (OmA) and cuff tear arthropathy (CTA). Additionally, the potential of immunohistochemical tissue biomarkers in reflecting the degeneration status of humeral head cartilage was evaluated. Methods. Specimens of the humeral head and synovial tissue from 12 patients with OmA, seven patients with CTA, and four body donors were processed histologically for examination using different histopathological scores. Osteochondral sections were immunohistochemically stained for collagen type I, collagen type II, collagen neoepitope C1,2C, collagen type X, and osteocalcin, prior to semiquantitative analysis. Matrix metalloproteinase (MMP)-1, MMP-3, and MMP-13 levels were analyzed in synovial fluid using enzyme-linked immunosorbent assay (ELISA). Results. Cartilage degeneration of the humeral head was associated with the histological presentation of: 1) pannus overgrowing the cartilage surface; 2) pores in the subchondral bone plate; and 3) chondrocyte clusters in OmA patients. In contrast, hyperplasia of the synovial lining layer was revealed as a significant indicator of inflammatory processes predominantly in CTA. The abundancy of collagen I, collagen II, and the C1,2C neoepitope correlated significantly with the histopathological degeneration of humeral head cartilage. No evidence for differences in MMP levels between OmA and CTA patients was found. Conclusion. This study provides a comprehensive histological characterization of humeral cartilage and synovial tissue within the glenohumeral joint, both in normal and diseased states. It highlights synovitis and pannus formation as histopathological hallmarks of OmA and CTA, indicating their roles as drivers of joint inflammation and cartilage degradation, and as targets for therapeutic strategies such as rotator cuff reconstruction and synovectomy. Cite this article: Bone Joint Res 2024;13(10):596–610

Aims. This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder. Methods. A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient’s shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid. Results. During the apprehension test, the centre of the humeral head was 1.0 mm (95% CI 0.0 to 2.0) more inferior on the glenoid for the ASI shoulder compared with the healthy shoulder. Furthermore, the contact point of the ASI shoulder was 1.4 mm (95% CI 0.3 to 2.5) more anterior and 2.0 mm (95% CI 0.8 to 3.1) more inferior on the glenoid compared with the healthy shoulder. The contact point of the ASI shoulder was 1.2 mm (95% CI 0.2 to 2.6) more anterior during the apprehension test compared to the relocation test. Conclusion. The humeral head centre was located more inferior, and the GHJ contact point was located both more anterior and inferior during the apprehension test for the ASI shoulders than the healthy shoulders. Furthermore, the contact point displacement between the apprehension and relocation test revealed increased joint laxity for the ASI shoulder than the healthy shoulders. These results contribute to existing knowledge that ASI shoulders with glenoid bone loss may also suffer from inferior shoulder instability. Cite this article: Bone Joint J 2024;106-B(10):1133–1140

Aims. Oxidized zirconium (OxZi) and highly cross-linked polyethylene (HXLPE) were developed to minimize wear and risk of osteolysis in total hip arthroplasty (THA). However, retrieval studies have shown that scratched femoral heads may lead to runaway wear, and few reports of long-term results have been published. The purpose of this investigation is to report minimum ten-year wear rates and clinical outcomes of THA with OxZi femoral heads on HXLPE, and to compare them with a retrospective control group of cobalt chrome (CoCr) or ceramic heads on HXLPE. Methods. From 2003 to 2006, 108 THAs were performed on 96 patients using an OxZi head with a HXLPE liner with minimum ten-year follow-up. Harris Hip Scores (HHS) were collected preoperatively and at the most recent follow-up (mean 13.3 years). Linear and volumetric liner wear was measured on radiographs of 85 hips with a minimum ten-year follow-up (mean 14.5 years). This was compared to a retrospective control group of 45 THAs using ceramic or CoCr heads from October 1999 to February 2005, with a minimum of ten years’ follow-up. Results. Average HHS improved from 50.8 to 91.9 and 51.0 to 89.8 in the OxZi group and control group, respectively (p = 0.644), with no osteolysis in either group. Linear and volumetric wear rates in the OxZi group averaged 0.03 mm/year and 3.46 mm. 3. /year, respectively. There was no statistically significant difference in HHS scores, nor in linear or volumetric wear rate between the groups, and no revision for any indication. Conclusion. The radiological and clinical outcomes, and survivorship of THA with OxZi femoral heads and HXLPE liners, were excellent, and comparable to CoCr or ceramic heads at minimum ten-year follow-up. Wear rates are below what would be expected for development of osteolysis. OxZi-HXLPE is a durable bearing couple with excellent long-term outcomes. Cite this article: Bone Joint J 2024;106-B(3 Supple A):38–43

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

Aims. Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty. Methods. Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 September 1999 and 31 December 2020 who underwent hemiarthroplasty for the treatment of a hip fracture with the following implants were included: a cemented monoblock Exeter Trauma Stem (ETS), cemented Exeter V40 with a bipolar head, a monoblock Thompsons prosthesis (Cobalt/Chromium or Titanium), and an Exeter V40 with a Unitrax head. Overall and age-defined cumulative revision rates were compared over the ten years following surgery. Results. A total of 41,949 hemiarthroplasties were included. Exeter V40 with a Unitrax head was the most commonly used (n = 20,707, 49.4%). The overall rate of revision was small. A total of 28,201 patients (67.2%) were aged > 80 years. There were no significant differences in revision rates across all designs of hemiarthroplasty in patients of this age at any time. The revision rates for all designs were < 3.5%, three years postoperatively. At subsequent times the ETS and Exeter V40 with a bipolar head performed well in all age groups. The unadjusted ten-year mortality rate for the whole cohort was 82.2%. Conclusion. There was no difference in implant survival between all the designs of hemiarthroplasty in the first three years following surgery, supporting the selection of a cost-effective design of hemiarthroplasty for most patients with an intracapsular fracture of the hip, as determined by local availability and costs. Beyond this, the ETS and Exeter bipolar designs performed well in all age groups. Cite this article: Bone Joint J 2023;105-B(8):864–871

Aims. Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD. Methods. A total of 1,453 DM components were implanted at a single academic institution between January 2010 and December 2021: 695 in primary and 758 in revision THA. Of these, 49 presented with a dislocation of the large DM head and five presented with an IPD. At the time of closed reduction of the large DM dislocation, six additional IPDs occurred. The mean age was 64 years (SD 9.6), 54.5% were female (n = 6), and mean follow-up was 4.2 years (SD 1.8). Of the 11 IPDs, seven had a history of instability, five had abductor insufficiency, four had prior lumbar fusion, and two were conversions for failed fracture management. Results. The incidence of IPD was 0.76%. Of the 11 IPDs, ten were missed either at presentation or after attempted reduction. All ten patients with a missed IPD were discharged with a presumed reduction. The mean time from IPD to surgical treatment was three weeks (0 to 23). One patient died after IPD prior to revision. Of the ten remaining hips with IPD, the DM head was exchanged in two, four underwent acetabular revision with DM exchange, and four were revised to a constrained liner. Of these, five (50%) underwent reoperation at a mean 1.8 years (SD 0.73), including one additional acetabular revision. No patients who underwent initial acetabular revision for IPD treatment required subsequent reoperation. Conclusion. The overall rate of IPD was low at 0.76%. It is essential to identify an IPD on radiographs as the majority were missed at presentation or after iatrogenic dissociation. Surgeons should consider acetabular revision for IPD to allow conversion to a larger DM head, and take care to remove impinging structures that may increase the risk of subsequent failure. Cite this article: Bone Joint J 2024;106-B(5 Supple B):98–104

Aims. Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied. Methods. In an observational cohort study on 8,031 FNF patients with THA between January 2005 and December 2014, Swedish Arthroplasty Register data were linked with the National Patient Register, recording the total dislocation rates at one year and revision rates at three years after surgery. The cumulative incidence of events was estimated using the Kaplan-Meier method. Cox multivariable regression models were fitted to calculate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of dislocation, revision, or mortality, stratified by surgical approach. Results. The cumulative dislocation rate at one year was 8.3% (95% CI 7.3 to 9.3) for patients operated on using the posterior approach and 2.7% (95% CI 2.2 to 3.2) when using the direct lateral approach. In the posterior approach group, use of DMC was associated with reduced adjusted risk of dislocation compared to 32 mm heads (HR 0.21 (95% CI 0.07 to 0.68); p = 0.009). This risk was increased with head sizes < 32 mm (HR 1.47 (95% CI 1.10 to 1.98); p = 0.010). Neither DMC nor different head sizes influenced the risk of revision following the posterior approach. Neither articulation was associated with a statistically significantly reduced adjusted risk of dislocation in patients where the direct lateral approach was performed, although this risk was estimated to be HR 0.14 (95% CI 0.02 to 1.02; p = 0.053) after the use of DMC. DMC inserted through a direct lateral approach was associated with a reduced risk of revision for any reason versus THA with 32 mm heads (HR 0.36 (95% CI 0.13 to 0.99); p = 0.047). Conclusion. When using a posterior approach for THA in FNF patients, DMC reduces the risk of dislocation, while a non-significant risk reduction is seen for DMC after use of the direct lateral approach. The direct lateral approach is protective against dislocation and is also associated with a lower rate of revision at three years, compared to the posterior approach. Cite this article: Bone Joint J 2022;104-B(7):844–851

Aims. The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids. Methods. Intact right cadaveric shoulders from donors aged between 50 and 65 years were assigned to a ceramic group (n = 8, four male cadavers) and a metal group (n = 9, four male cadavers). A dedicated shoulder wear simulator was used to simulate daily activity by replicating the relevant joint motion and loading profiles. During testing, the joint was kept lubricated with diluted calf serum at room temperature. Each test of wear was performed for 500,000 cycles at 1.2 Hz. At intervals of 125,000 cycles, micro-CT scans of each glenoid were taken to characterize and quantify glenoid wear by calculating the change in the thickness of its articular cartilage. Results. At the completion of the wear test, the total thickness of the cartilage had significantly decreased in both the ceramic and metal groups, by 27% (p = 0.019) and 29% (p = 0.008), respectively. However, the differences between the two were not significant (p = 0.606) and the patterns of wear in the specimens were unpredictable. No significant correlation was found between cartilage wear and various factors, including age, sex, the size of the humeral head, joint mismatch, the thickness of the native cartilage, and the surface roughness (all p > 0.05). Conclusion. Although ceramic has better tribological properties than metal, we did not find evidence that its use in hemiarthroplasty of the shoulder in patients with healthy cartilage is a better alternative than conventional metal humeral heads. Cite this article: Bone Joint J 2024;106-B(11):1273–1283