From 1982 to 1987, we randomised prospectively 413 patients requiring primary total hip replacements to receive either a Stanmore or Charnley prosthesis. They were reviewed by an independent observer in an attempt to correlate a number of factors including femoral head size with longevity. There were 213 Stanmore hips and 200 Charnley prostheses. At five to ten years (mean 6.5) 76 patients had died and 16 arthroplasties had required revision. Seven were radiologically loose in asymptomatic patients. There was only one case of deep infection.

We found no difference statistically in the clinical outcome or in the revision rate of 4% in the two types of prosthesis. The revision rate was greater for trainees than for senior operating surgeons, and there were recognisable technical errors in seven of the nine Stanmore, and four of the seven Charnley replacements which required revision. Retrospective radiological analysis of a random subset of 51 Charnley and 57 Stanmore femoral components showed no difference in femoral subsidence, but in 14 patients who had had bilateral replacements with one femoral component of each type, there was greater early subsidence of the Stanmore prosthesis.

Our results confirm that conventional cemented total hip replacements give acceptable results in a general teaching unit, and we found no evidence of any effect of the size of the femoral head on wear or loosening at five to ten years.

We developed a 12-item questionnaire for completion by patients having total hip replacement (THR). A prospective study of 220 patients was undertaken before operation and at follow-up six months later. Each completed the new questionnaire as well as the SF36, and some the Arthritis Impact Measurement Scales (AIMS). An orthopaedic surgeon assessed the Charnley hip score.

The single score derived from the questionnaire had a high internal consistency. Reproducibility was examined by test-retest reliability and was found to be satisfactory. The validity of the questionnaire was established by obtaining significant correlation in the expected direction with the Charnley scores and relevant scales of the SF36 and the AIMS. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at the follow-up. The standardised effect size for the new questionnaire compared favourably with that for the SF36 and the AIMS.

The new questionnaire provides a measure of outcome for THR which is short, practical, reliable, valid and sensitive to clinically important changes.

Three radiological methods are commonly used to assess the outcome of total hip replacement (THR). They aim to record the appearance of lucent areas and migration of the prosthesis in a reproducible manner. Two of them were designed to monitor the implant through time and one to grade the quality of cementing. We have measured the level of inter- and intraobserver agreement in all three systems.

We randomised 30 patients to receive either finger packing or retrograde gun cementing during Charnley hip replacements. The postoperative departmental radiographs were evaluated in a blinded study by two orthopaedic trainees, two consultants and two experts in THR. The trainees and consultants repeated the exercise at least two weeks later. We used the unweighted kappa statistic to establish the levels of agreement.

In general, intraobserver agreement was moderate but interobserver agreement was poor, with levels similar to or less than those expected by chance. Our results indicate that such systems cannot provide reliable data from centres in different parts of the world, with various levels of surgeon evaluating radiographs at differing time intervals. We discuss the problem and suggest some methods of improvement.

We implanted 300 uncoated cementless PM prostheses into 271 patients and followed 251 (92.6%) of them for four to seven years.

By then 37 had already been revised for aseptic and three for septic loosening. The survival rate with implant failure as the endpoint was 88.8% for the cup and 85.3% for the stem after six years. There was a higher risk of implant loosening in congenital dysplasia, unilateral hip arthroplasty and obesity.

The results of 225 unrevised hip replacements were assessed by questionnaire. Only 27.4% of the patients were completely free from pain and 17.9% had pain on walking any distance or at all times. The walking distance was for less than 30 minutes in 40%.

Because of the poor results in comparison with other prostheses we do not recommend further use of the uncoated PM prosthesis.

We report the radiological and clinical outcome of a press-fit (SLF) acetabular component at two to three years in two groups of patients having primary total hip replacement. In 69 the implant was coated with hydroxyapatite (HA) and in 40 it was uncoated. The stability of the cup was assessed by measurement of proximal migration and change in the angle of inclination.

The clinical results in the two groups did not differ significantly, and the mean proximal linear wear was similar in both. Fewer radiolucent lines (RLLs) were seen on the radiographs of cups coated with HA.

The mean proximal migration was studied by calculating regression lines for each patient using migration measurements: for the SLF+HA group the mean slope was 0.06 mm/year and for the SLF–HA group 0.20 mm/year (p = 0.22). The change in the angle of inclination during follow-up was also consistently smaller in HA–coated cups. Using regression methods the SLF+HA group had a mean slope of 0.08°/year and the SLF-HA group 0.44°/year (p = 0.023).

Partial HA coating appeared to have no effect on the clinical outcome or on the rate of wear of polyethylene, but there was a trend towards a reduced rate of proximal migration, and a significant reduction in rotational migration and the number of radiolucent lines. This suggests that HA coating enhances the stability of this acetabular component.

We studied the effect of surgical experience on the dislocation rate after 4230 primary total hip arthroplasties (THAs) all performed using the posterior approach at three orthopaedic centres at major county hospitals. There were 129 postoperative (3%) dislocations.

Twice the number of dislocations were registered for inexperienced surgeons as for their more experienced colleagues. This frequency of dislocation levelled off with increasing numbers of operations and remained constant after approximately 30. For every ten primary THAs performed annually, the risk of dislocation decreased by 50%.

We randomised 250 patients undergoing unilateral, elective hip arthroplasty for osteoarthritis to receive either a cemented or a non-cemented Mallory Head prosthesis. Aspirin was used as prophylaxis against thromboembolism during the first half of the study and adjusted-dose warfarin during the second half. Postoperatively, all patients were asked to have bilateral venography and 80% agreed. All were evaluated clinically for pulmonary embolism.

There was no difference in the frequency of deep-venous thrombosis between the two groups (50% cemented v 47% non-cemented, p = 0.73; 95% CI of the difference −13.6% to 19.3%). Three of the 64 patients (5%) in whom venography had demonstrated isolated distal thrombi developed pulmonary emboli.

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures.

There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss.

In a prospective randomised trial 76 knees with isolated degenerative changes in the medial femoral condyle of grades 3 or 4 were treated by either arthroscopic debridement (40) or washout (36).

All knees were followed up for at least one year and 58 for five years. The mean follow-up time was 4.5 years in the debridement group and 4.3 years in the washout group.

At one year 32 of the debridement group and five of the washout group were painfree and at five years 19 of a total of 32 survivors in the debridement group and three of the 26 in the washout group were also free from pain. The mean improvement in a modified Lysholm score was 28 for the debridement group at one year and 21 at five years. In the washout group it was only 5 at one year and 4 at five years.

For knees with lesions of the medial femoral condyle of grades 3 or 4, arthroscopic debridement appears to be the treatment of choice with over half the patients free from pain after five years.

We reviewed 1567 elective knee replacements performed between 1980 and 1990, using either the Total Condylar prosthesis with an all-plastic tibial component, or the Kinematic prosthesis which has a metal tibial tray. The ten-year probability of survival was 92.1% for the Total Condylar design and 87.9% for the Kinematic. The difference was mainly due to 16 revisions required in the Kinematic series for fracture of the metal base-plate. This was the most common cause of aseptic failure in this group.

These fractures were strongly associated with a preoperative varus deformity (hazard ratio (HR) 8.8) and there was a slightly increased risk in males (HR 1.9) and in osteoarthritic knees (HR 1.8). In the nine fractures which occurred within four years of primary implantation (group 1), failure to correct adequately a preoperative varus deformity and the use of a bone graft to correct such a deformity were both strongly associated with fracture (HR 13.9 and 15.8, respectively). In eight fractures which occurred more than five years after primary replacement (group 2) we could detect no significant risk factors.

Early complications occurred in two patients after the 16 revision procedures for tray fracture. One had a deep infection and the other refracture of the tray.

We studied 40 patients in whom the patella was not severely deformed and who were undergoing primary total knee arthroplasty (TKA) for osteoarthritis by one surgeon using one type of prosthesis. They were randomly allocated either to have the patella retained or resurfaced with a cemented, all-polyethylene component regardless of the state of the patellar articular cartilage. Apart from removal of osteophytes, no surgery was undertaken on the retained patellae. All 38 surviving patients were evaluated at three years using the HSS knee score and a new, specifically designed Patellar score (maximum score of 30). No TKA was revised, but two patients in the resurfacing group had a further unrelated procedure.

The mean HSS and Patellar scores at follow-up were 89 and 28 in the patellar retention group and 83 and 26 in the patellar resurfacing group. Statistically significant lower scores for both were recorded in women and in heavier patients. Stair-climbing ability was significantly better in the retention group. Although there were no complications related to patellar resurfacing, in the medium term we did not find any significant benefit from resurfacing the patella during TKA for osteoarthritis if it was not severely deformed.

We have analysed the Constant-Murley (1987) assessment for 25 patients with shoulder pathology. We found the score easy to use, with low inter- and intraobserver errors, but sufficiently imprecise in repeated measurements to give concern in its use for clinical follow-up of patients.

We have calculated 95% confidence limits for a single assessment to be within 16 to 20 points in most cases. In addition, we found that all our subjects with instability as their main problem scored within five points of the maximum; this suggests that the scoring method may need to be revised for use on these patients.

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm² and group II, the control group, 30 impulses.

The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II.

Lesions of the anterior interosseous nerve in the forearm are rare and often misdiagnosed as tendon injuries. A consecutive series of 13 patients with this condition referred for electrodiagnosis is reviewed. Only three had originally a correct clinical diagnosis and three were initially considered to have tendon ruptures.

Five cases were of mechanical origin and seven due to ‘neuritis’. All showed electrophysiological abnormalities, most commonly involving the pronator quadratus. Late spontaneous recovery was common, and only one case had surgical exploration.

A distinctive and consistent pattern of degenerative change was seen in 560 acromioclavicular joints from dry bone skeletons of subjects over 40 years of age. An appreciation of this characteristic configuration is helpful at operation or when introducing a needle into the joint.

We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow.

We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months.

All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head.

Over an eight-year period up to 1983, a total of 322 consecutive patients had operations for ankle fractures; 176 were Weber type B and 128 type C. We were able to review 230 of these patients after a mean follow-up of six years (1 to 11) including 128 with Weber B and 102 with Weber C fractures.

We used an ankle score which combined symptoms and clinical and radiological findings, with a maximum score of 100 points. The mean score for all 230 was 92 (68 to 100). Fifteen of these patients had developed a distal synostosis between the tibia and fibula, three after a Weber B and 12 after a Weber C fracture. In 13 of these 15 ankles the synostosis had been visible radiologically within three months of the operation. In the other two there had been radiologically visible calcification at the three-month follow-up.

In 1993, we were able to review nine of the 15 patients with synostosis using the same scoring system. At a mean follow-up of 14 years (12 to 18) the mean score for those with synostosis was 91 (71 to 100), much the same as this group’s previous score and the mean score of the whole group of operated patients. We conclude that distal tibiofibular synostosis after ankle fracture usually causes few symptoms and does not generally require any treatment.

We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of avascular necrosis of the head.

Two fractures were Garden stage I, 12 stage II, and three stage III. We performed internal fixation under radiological control at a mean of five days (2 to 15) after injury using a titanium cannulated cancellous screw or a titanium compression hip screw. MRI was performed at one, six and 12 months and then yearly after operation. T1- and T2-weighted images were obtained by a spin-echo technique. The duration of follow-up of patients who did not subsequently require replacement of the head of the femur was from 2 to 5 years (mean 3.2).

One month after operation eight of the 17 hips showed a band of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images indicating lesions in the femoral head away from the fracture line. These were of three types: type I was a small infarct at the superolateral region of the femoral head and was seen in three hips; type II was a shallow lesion from the superolateral region to the fovea of the femoral head (three hips); and type III was a large lesion occupying most of the femoral head (two hips). No further changes were seen in the MRI after six months from operation. Collapse of the femoral head did not occur in the three hips with type-I lesions, but two of the three type-II hips and both type-III hips subsequently collapsed. At the final follow-up the three hips with a type-I lesion and one with a type-II were still asymptomatic but radiography showed sclerosis in the femoral head corresponding to the MRI lesions. The nine hips which showed no changes on MRI at one month had no abnormal findings on physical examination, radiography or MRI at final follow-up.

We evaluated the diagnostic accuracy of fine-needle aspiration biopsy in a prospective study of 300 patients with previously undiagnosed bone lesions. Patients with suspected local recurrence of a primary bone tumour or a metastatic lesion of a previously diagnosed malignancy were excluded. Fine-needle aspiration biopsy was performed under radiological control as an outpatient procedure.

The series was grouped into three major categories: 1) benign bone lesions including infections; 2) primary malignant bone tumours; and 3) metastases including lymphomas and myelomas. We compared the cytological diagnosis with the final diagnosis as assessed by histological examination and/or the clinical and radiological features.

Material considered conclusive for cytological diagnosis was obtained from 251 of the 300 patients. Of the 49 failures, there were 24 aspirates with insufficient cellular yield and 25 in which a diagnosis could not be made although the cytological material was adequate in quantity. Most of the inconclusive aspirates (36/49) were obtained from benign bone lesions.

The diagnosis was correct in 239 (95%) of the 251 cases providing adequate cytological material. There were eight (3%) falsely benign diagnoses, one (0.3%) falsely malignant, and three cases in which we were unable to differentiate between sarcoma and a metastasis. Chondrosarcoma (2/12) gave the greatest diagnostic difficulty and Ewing’s sarcoma the least (0/9). There were no decisive errors of treatment. All falsely benign or malignant diagnoses were questioned, and led to open biopsy since they did not correlate with the clinical and radiological features.

Our study suggests that fine-needle aspiration biopsy is a valid option for the diagnosis of bone tumours. It is a simple outpatient procedure which gives sufficient cytological material for the correct diagnosis in 80% of cases. As with histological analysis of material from open biopsy, the cytological assessment must agree with the clinical and radiological findings.

We have used the Ilizarov technique for the management of subarticular defects after the excision of giant-cell tumours in the proximal tibia in five patients. The defect was reconstructed with a segment of 5 to 6 cm obtained from the diaphysis of the affected tibia and by autogenous bone graft from the iliac crest. The newly developed defect in the diaphysis was reconstructed by distraction using the Ilizarov apparatus. Bone grafting at the docking site was performed soon after positioning the bone segments.

The mean length of the bone defect was 5.7 cm and the mean duration of external fixation was 233 days. The relative blood flow in the leg measured by ^99mTc angiography increased by 1.7 to 2.3 times that of the control level during distraction and consolidation. When seen at a mean of 43 months all patients showed a normal range of motion in the knee and ankle with no collapse of the articular surfaces.

Two acetabula which contained large bone allografts introduced at revision arthroplasty were obtained at post-mortem. The allografts had been placed in superior defects to support cementless acetabular components, and both hips were functioning well at the time of death. Clinical radiographs demonstrated apparent healing of graft to host bone, no graft collapse and stability of the acetabular components. Microscopic examination of sections through these specimens showed that the bulk allografts were encapsulated in fibrous tissue. Vascularity was increased at the host-graft interface, but there was limited evidence of bone union between the graft and the host. In the few areas where union had occurred, revascularisation extended no more than 2 mm beyond the graft-host interface.

Within the body of the graft, the acellular matrix of trabecular bone maintained structural integrity up to 48 months after surgery. In areas where the allograft was adjacent to an implant, there was fibrous tissue orientated parallel to the implant surface. The acetabulum which contained a porous-coated component showed evidence of bone growth into the porous surface where it was in contact with viable host bone. No ingrowth occurred in areas where the porous coating was in contact with the graft. Although the grafts were functioning well, allograft revascularisation and remodelling were minimal, and the radiological appearance of healing did not correlate with histological findings.

We assessed the prevalence of abnormal ankle reflexes in 1074 adult patients attending orthopaedic clinics and related it to age. Those with possible pathological causes of reflex loss were excluded.

The absence of one or both reflexes was significantly related to increasing age; all patients under 30 years had both reflexes. Few had absent reflexes between 30 and 40 years, but over 40 years, the proportion with both reflexes absent increased rapidly from 5% (40 to 50 years) to 80% (90 to 100 years). Unilateral absence did not show the same pattern of increase being 3% to 5% at 40 to 60 years and 7% to 10% at over 60 years.

Our results suggest that a significant number of ‘normal’ adults have unilateral absence of an ankle reflex, but this finding is rare enough to be a definite clinical sign, irrespective of age.

We report the findings from independent prospective clinical and laboratory-based joint-simulator studies of the performance of ceramic femoral heads of 22.225 mm diameter in cross-linked polyethylene (XLP) acetabular cups. We found remarkable qualitative and quantitative agreement between the clinical and simulator results for the wear characteristics with time, and confirmed that ceramic femoral heads penetrate the XLP cups at only about half the rate of otherwise comparable metal heads.

In the clinical study, 19 hips in 17 patients were followed for an average of 77 months. In the hip-joint simulator a similar prosthesis was tested for 7.3 million cycles.

Both clinical and simulator results showed relatively high rates of penetration over the first 18 months or 1.5 million cycles, followed by a very much lower wear thereafter. Once an initial bedding-in of 0.2 mm to 0.4 mm had taken place the subsequent rates of penetration were very small. The initial clinical wear during bedding-in averaged 0.29 mm/year; subsequent progression was an order of magnitude lower at about 0.022 mm/year, lower than the 0.07 mm/year in metal-to-UHMWP Charnley LFAs.

Our results show the excellent tribological features of alumina-ceramic-to-XLP implants, and also confirm the value of well-designed joint simulators for the evaluation of total joint replacements.

We describe a technique for measuring the Stiffness of regenerate bone after leg lengthening. This allows early identification of slow healing by reference to normal patterns. We determined the time of removal of the fixator from clinical and radiological information independent of the stiffness result.

In a series of 30 leg lengthenings there were no refractures when the tibial stiffness had reached 15 Nm/° or the femoral stiffness 20 Nm/°. Three refractures occurred at lower stiffness values. The technique is simple to perform, will allow a reduction in plain radiography and is recommended for routine postoperative management.

We have reviewed 16 patients treated by leg lengthening for various forms of Turner dwarfism with regard to the long period of healing and the complications. We consider that Turner dwarfism is a suitable indication for leg lengthening because of the moderate length deficit and the morphological appearance of the patients, and have introduced an improved programme of management to deal with the problems encountered.

We reviewed 52 children, born between 1974 and 1985 with spina bifida affecting L3 and L4, who had dislocated hips. Their motor function was stable and they were able to walk at the time of dislocation. They were interviewed and examined physically and radiologically. Physical function was measured by the Rand Health Insurance Study questionnaire (HIS), the Childhood Health Assessment questionnaire (CHAQ), and by determining the functional level of ambulation according to Hoffer et al (1973). In a subgroup of 12 patients with L4 level of involvement from both treatment groups we measured the metabolic energy consumption while walking.

Thirty patients (49 hips) had been treated by operative relocation and 22 conservatively. Ten of the hips treated by operation subluxated or redislocated. The function in the two groups (conservative v operated) was similar (HIS score 7.8 v 8.0, p = 0.45; CHAQ 14 v 13, p = 0.2; level of mobility 0.61 v 0.63, p = 0.5). Patients in whom operation had failed had worse function than did those with successful surgery (HIS score 8.8 v 6.1, p = 0.025) and those with successful surgery had better function than patients treated conservatively (HIS score 8.8 v 8.0, p = 0.15). Function in patients with failed operations, however, was worse than in those who did not have surgical treatment (HIS score 6.6 v 7.8, p = 0.07). In the 12 so examined the operated group had a 30% more energy-efficient gait (0.271 v 0.361 ml O₂ kg/m, p = 0.05).

Patients with failed operations had worse function than those who were not operated on. The benefit of surgical relocation of the dislocated hips was marginal.

We reviewed the results of anterior hip release for fixed flexion deformity in 57 hips in 38 children with spina bifida at an average follow-up of 8.9 years (2 to 22). The indication for this operation was a fixed flexion deformity of more than 30° which interfered with function.

In 43 hips there was a good outcome in that the fixed flexion deformity remained less than 30° at follow-up. Four hips had a good initial result but deteriorated after an average of five years, and ten had a poor outcome with deformity of over 30°. Six hips required a repeated anterior hip release and two of these were successful.

The success of anterior hip release could not be related to the neurological level or the age at operation. Successful surgery correlated with the walking ability of the child at the latest follow-up.

Most obstetric brachial plexus palsies are due to rupture of the upper roots in babies whose delivery was complicated by shoulder dystocia. If treated by early exploration and grafting, they have a favourable prognosis.

We reviewed 36 babies who had had an obstetric brachial plexus palsy after a breech delivery and found that they had a different pattern of injury; 81% had avulsion of the upper roots. This injury cannot be treated satisfactorily by exploration and microsurgical grafting and carries a considerably worse prognosis for shoulder function.

In 17 patients (eleven males, six females) with Morquio-Brailsford syndrome (mucopolysaccharidosis IV) we have used onlay femoral and tibial autografts placed posteriorly and secured to the laminae of C1 and C2 to obtain satisfactory occipito-C1/C2 posterior fusion. They were immobilised postoperatively in a halo-plaster body jacket for four months. The age at operation varied between three and 28 years. Those with myelopathic symptoms of recent onset made some recovery, but severely myelopathic patients showed little or no recovery.

We advise prophylactic occipitocervical fusion in these patients since the cartilaginous dens is not strong enough to ensure atlanto-axial mechanical stability.

In a prospective trial we performed MRI of the spine and hind brain in 31 patients with scoliosis of onset between the ages of four and 12 years.

In eight patients (26%) there was a significant neuroanatomical abnormality; there were six cases of Chiari-1 malformation associated with a syrinx, one isolated Chiari-1 malformation and one astrocytoma of the cervical spine. Four of these patients had left-sided curves.

There were no clinical features which could reliably identify those patients with abnormalities on MRI. In particular, the unilateral absence of abdominal reflexes was found to be non-specific (1 of 8 of patients with neuroanatomical abnormalities (12.5%) v 2 of 23 with normal scans (8.7%)).

In view of the established risks of surgical correction of scoliosis in the presence of undecompressed syringomyelia and the possible improvement that may follow decompression of the foramen magnum, we feel that MRI of all patients with scoliosis of juvenile onset should be obligatory.