The modern generation of hip resurfacing arthroplasties was developed in the early 1990’s with one of the original designs being the McMinn Resurfacing Total Hip System. This was a hybrid metal on metal prosthesis, with a smooth hydroxyapetite coated press fit mono block cobalt chrome shell with a cemented femoral component. Although no longer produced in this form, lessons may be learned from this original series of components. With metal on metal resurfacing arthroplasty now facing criticisms and concerns with regard function, bone preservation capability and soft tissue issues such as ‘pseudotumors’, it is the aim of this long-term study to assess the outcome and survival of an original series of resurfacing arthroplasties.

27 resurfacing arthroplasties were performed in 25 consecutive patients between June 1994 and November 1996. 16 right hips and 11 left were performed in 14 female patients and 11 male patients. The average age at the time of surgery was 50.5 years (SD 7.9, range 30–63). All surgeries were performed by a single surgeon using a posterior lateral approach. Following the initial early care, each patient received bi-annual follow up along with open access to the clinic with any concerns or complications. A retrospective review of the case notes was conducted and outcome scores retrieved from a prospectively updated database. Radiographs were analyzed and a Kaplan Meier survival chart was constructed for the group.

At latest review 3 patients have died (5yrs, 8yrs and 13.8yrs) and 1 patient has been lost to follow up (5yrs). 7 resurfacings have required revision, all due to acetabular loosening, at a mean follow up of 7 years 11months (SD 2.03years, range 4–10). Metallosis was documented in 4 of the revision cases, however no extensive soft tissue inflammation or ‘pseudotumor’ identified. The mean follow up of the remaining 16 hips is 12years and 10months (SD 12.8months, Range 10.4yrs–14.0 years). The Kaplan Meier survival at a minimum follow up of 10 years is 75.8% (95% CI 0.67–0.95). Mean Oxford hip scores at latest follow up was 20.6 (SD 8.8, range 12–38). There was no significant difference between cup inclination angles for the surviving cohort and those who required a revision procedure with mean cup inclinations of 52.5 (SD 5.5, range 45–60) and 58 degrees respectively (SD 9.1, range 50–70)(p=0.255).

This original series of hip resurfacings, with up to 14 years follow up, shows a survival of 76% at the minimum follow up of 10 years. All failures were due to loosening of the smooth backed acetabulum, which with a modern porous coating, failure may have been avoided or delayed. Despite high inclinations angles no soft tissue reactions were identified within this series. No femoral failures were identified suggesting unlike much literature focus, long-term failure may not be related to the femoral head or neck.

This study was designed to determine the risk of femoral neck fracture after anterior or posterior notching of the femoral neck. The anterior femoral neck is under tensile forces during gait similarly to the superior neck [6].

Method: Fortyseven 4th generation synthetic femora were implanted with Birmingham Hip Resurfacing pros-theses (Smith & Nephew Inc. Memphis, USA). Implant preparation was performed using imageless computer navigation (VectorVision SR 1.0, BrainLAB, Germany). The prosthesis was initially planned for neutral version and translated anterior, or posterior, to create a femoral neck notch. The femora were fixed in a single-leg stance and tested with axial compression. This method enabled comparison with previously published data. The synthetic femora were prepared in 8 experimental groups: 2mm and 5mm anterior notches, 2mm and 5mm posterior notches, neutral alignment with no notching (control), 5mm superior notch, 5mm anterior notch tested with the femur in 25° flexion and 5mm posterior notch tested with the femur in 25° extension

We tested the femora flexed at 25° flexion to simulate loading as seen during stair ascent. [3] The posterior 5mm notched femoral necks were tested in extension to simulate sporting activities like running. The results were compared to the control group in neutral alignment using a one- way ANOVA:

Results: Testing Group Mean load to failure Significance

Neutral (Control) 4303.09 ± 911.04N

The anterior 5mm notch tested in single-leg stance and anterior notch in flexion displayed lower compressive loads to failure (3374.64N and 3048.11N). The mean load to failure value for the posterior 5mm notches in extension was 3104.62N compared to 4303.09N for the control group.

Our data suggests that anterior and posterior 2mm notches are not significantly weaker in axial compression. The anterior 5mm notches was not significant in axial compression (p=0.38), but trended towards significance in flexion (p=0.087). A 5mm posterior notch was not significant. (p=0.995, p=0.117). The 5mm superior notch group was significantly weaker with axial compression supporting previous published data (p=0.003).

Conclusion: We conclude that anterior and posterior 2mm notching of the femoral neck has no clinical implications, however a 5mm anterior femoral neck notch may lead to fracture. The fracture is more likely to occur with stair ascent rather than normal walking given the reduction in strength noted after testing in flexion. Posterior 5mm notches are not likely to fracture. Hip resurfacing is commonly performed on active patients and 5mm notching of anterior cortex has clinically important implications.

The use of metal on polyethylene articulations was a key development in establishing total hip arthroplasty as a successful and reproducible treatment for end stage osteoarthritis. In order to ensure implant durability in relatively younger populations, there is a need for alternative, wear resistant bearing surfaces. Oxidized Zirconium (Oxinium, Smith & Nephew, Inc., Memphis, TN) is a relatively new material that features an oxidized ceramic surface chemically bonded to a tough metallic substrate. This material has demonstrated the reduced polyethylene wear characteristics of a ceramic, without the increased risk of implant fracture. The purpose of the current investigation was to assess early clinical outcomes following primary total hip arthroplasty with Oxinium versus Cobalt Chrome femoral heads.

One-hundred primary THA procedures were prospectively performed in 100 patients. There were 52 males and 48 females. Using a process of sealed envelope randomization, patients were divided into 2 groups. Group 1 consisted of fifty patients, each receiving primary THA implants with an Oxinium femoral head (OX). The mean age of each patient was 51 years (SD 10.8, Range 22–74) with 26 males and 24 females. Group 2 also consisted of 50 patients. Within this group again each patient received primary THA implants however with a cobalt-chrome femoral head (CC). Demographics were similar with mean age 51 years (SD 11.0, Range 19–76) and again 26 males and 24 females.

The current study reports clinical outcome measures for both the OX and CC groups at a minimum follow-up of 2 years postoperatively. At the time of latest follow-up, stem survival for both groups was 98%. There was a significant improvement in all clinical outcome scores between preoperative and 2 year postoperative time periods for both bearing groups (p< 0.003). There were no significant differences between bearing groups for any of the clinical outcome scores at final follow-up (p> 0.159). Mean Harris Hip Scores at 2 years postoperatively were 92 and 92.5 for OX and CC, respectively (range; 65–100 OX, 60–100 CC). For SF-12, both the Physical Component Summary Scale (PCS) and the Mental Component Summary Scale (MCS) are reported. Mean PCS scores at final follow-up were 45.2 and 49.21 for OX and CC (range; 27.1–56.7 OX, 26.3–61.8 CC). Mean MCS scores were 53.8 and 52.57 for OX and CC (range; 39.2–65.5 OX, 34.3–64 CC). Mean final WOMAC scores are reported as 84.9 and 87 for OX and CC, respectively.

The current data suggest that total hip arthroplasty utilizing Oxinium femoral heads is safe and effective. Additional follow-up of the current cohort will be performed in order to fully assess mid- to long-term clinical outcomes.

Total hip replacement in the young active patient remains one of the major challenges in orthopaedics today. The use of ultra high molecular weight (UHMW) polyethylene acetabular liners is known to cause polyethylene wear related osteolysis, the major limiting factor in its use in the younger active patient. Modern alumina ceramic articulations have been developed in order to reduce wear and avoid polyethylene debris. This prospective randomized long-term study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on UHMW polyethylene articulation (CP). In the younger active patient, is one option superior to the other with regard to patient satisfaction, osteolysis and implant longevity?

56 hips in 55 patients with mean age 42.2 (range 19–56) each received uncemented components (Wright Medical) and a 28mm alumina head with acetabular liner selected via sealed envelope randomization following anesthetic induction. Subsequent regular clinical and radiologic follow up measured patient outcome scores and noted any radiological changes.

26 CP hips and 30 CC hips were evaluated. One failure required revision in each group. Mean St Michael’s outcome score for each group with up to 10 years follow-up (median 8 years, range 1–10) was 22.8 and 22.9 respectively (p=0.057). Radiographs with a minimum 5 years post-operative follow-up were analyzed in 42 hips (23 CC and 19 CP). Radiolucency of all 3 acetabular zones was identified in one of the CP hips. There was no evidence of osteolysis or loosening identified in the remaining hips. The mean time of wear measurement for the CC group was 8.3 years (SD 1.3, Range 4.8–10.1 years) and for the CP group was 8.1 years (SD 0.9, Range 6.1–9.2 years)(p=0.471). Wear was identified in all but one of the CP replacements but only 12 of 23 CC articulations. The mean wear for the CC group was 0.14 mm (SD 0.16, Range 0–0.48 mm) and for the CP group was 0.89 mm (SD 0.6, Range 0–2.43 mm)(p< 0.001). Extrapolating the annual wear rate from these figures, the respective wear is 0.02mm for the CC group compared to 0.11mm per year for the CP group.

To our knowledge this is the first long term randomized trial comparing in vivo ceramic-on-ceramic with ceramic-on-conventional polyethylene hip articulations. Other than significantly greater wear in the polyethylene group there was no significant difference in long-term outcome scores between the two groups with up to 10 years of follow-up. The use of a ceramic-on-ceramic bearing is a safe and durable option in the young patient avoiding the concerns of active metal ions and osteolytic polyethylene debris. These patients remain under review.

Cognitive dysfunction has been well documented following total knee replacement. Possible causes that have been postulated include cerebral emboli, post-operative complications and pain. The aim of this study is to compare cognitive decline in patients undergoing conventional total knee replacement (TKR), navigated total knee replacement and total hip replacement (THR).

We prospectively analysed 75 patients undergoing lower limb arthroplasty. Group 1 consisted of 25 conventional TKR’s, group 2 consisted of 25 navigated TKR’s and group 3 consisted of 25 THR’s. Cognitive function was assessed by 11 validated neuropsychological tests preoperatively, at 1 week post-operatively and at 6 months post-operatively. Testing was carried out by a clinical psychologist.

At day 6 post-operatively 55% of group 1, 83% of group 2 and 61% of group 3 patients had a significant cognitive decline. Group 2 had a significantly greater cognitive decline at day 6 compared to the other 2 groups. At 6 months significant cognitive decline was found in all 3 groups to 21%, 16% and 34% respectively. Group 2 demonstrated the greatest improvement in cognition from day 6 to 6 months post-operatively

Significant cognitive decline occurs in two-thirds (66%) of all patients undergoing lower limb arthroplasty at day 6 and remains significant in a quarter (25%) of patients at 6 months. There was no significant difference in cognitive decline in patients undergoing hip and knee arthroplasty.

Private companies now offer risk assessment packages to Trusts. Data are collected using ICD coding and complication rates for individual surgeons are calculated and published. A risk assessment document was recently published at the Royal Gwent Hospital presenting complication rates and misadventures on league tables of specialty and consultants. Serious concerns were raised about the quality of the data. We undertook a study to independently evaluate the accuracy of data used to calculate these complication rates.

Two Orthopaedic Surgeons with the highest published complication rates were studied. The notes of patients who had suffered complications were retrieved and the published complication data was compared with the clinical interpretation of the actual complication. One hundred and fifty reported complications were analyzed.

In most cases data accuracy was woefully inadequate. For example revision procedures were counted as complications for the revision surgeon irrespective of who carried out the primary procedure. The normal work-up of these patients including procedures to investigate the presence of infection are recorded as complications with some patients being recorded as having up to four separate complications. Misadventures published for surgeons included dural tap during epidural anesthesia. The results of this study highlight the potentially devastating consequences of data inaccuracy. Inaccurate published data on complications, used to form league tables for individual surgeons, can be career- jeopardizing. We advocate that consultation with the clinicians involved should always occur before data are published so that these inaccuracies can be picked up and the potentially damming consequences of falsely high complication rates can be avoided.

Introduction and Aims: Despite comprehensive literature on knee arthroplasty outcomes there is a paucity of data on patient satisfaction and functional outcomes. We have examined patient satisfaction, function, and time to return to sport and activities of daily living.

Method: A retrospective cohort study using self-assessment forms reviewed all patients who had undergone an Oxford uni-compartmental knee replacement in one centre from 2000 to 2003 at a minimum one-year post-surgery. One hundred and fifty patients with 183 UKRs were reviewed. Twenty-two had bilateral surgery. The cohort contained 76 males and 74 females of mean age 71.5 years (range 52–90). Patients were assessed using the Oxford knee score and a further score of how ‘normal’ their knee felt. Physical activity was assessed according to Grimby’s scale. Sporting activity was assessed with regards to pre- and post-operative frequency, time taken to return to sport, and pain during and after exercise. Time to return to work was also noted.

Results: Mean Oxford knee score for males was 21.6 (range 12–43, SD 8.25) and females 22.8 (range 12–54, SD 9.78). Mean Grimby’s score for males was 4.1 (range 1–6, SD 1.2) and for females 3.6 (range 1–6, SDI.2). Mean time to return to walking as exercise was 7.9 weeks (range 1–47.6, SD 8.9), to swimming was 10 weeks (range 1–34.6, SD 9.9), to cycling 11.8 weeks (range 1–34.7, SD 11) to lawn bowling 24.5 weeks (range 4–104, SD 26.2) and golf 12.3 weeks (range 3–33.3, SD8.73). Return to sport, activities of daily living and return to work positively correlated to the patients’ perception of how ‘normal’ their knee felt.

Conclusion: This study observes activity levels and times to return to ADLs, work and sport that is a guide for patient education and post-operative expectation. When compared to a recent study of total knee arthroplasty patients from our institution the uni-compartmental patients were more satisfied and more active. Patients were more active pre-operatively and post-operatively, they were less likely to give up sport following surgery.

Introduction and Aims: The study was designed to compare the early results, prospectively, of the fixed-bearing Zimmer NexGen cruciate retaining (CR) and the Zimmer NexGen mobile-bearing knee (MBK) knee arthroplasty. The study was designed to determine whether differences exist in the clinical outcomes between patients receiving different types of bearings.

Method: Patients were randomly assigned to receiving either fixed or mobile bearings. Patients were blinded but not assessors to the type of arthroplasty. The study commenced in June 2000. By November 2002, 69 and 70 patients had been recruited into the CR and MBK groups respectively. Consultants were present in 92% of operations and the rest were performed by a senior registrar. The major indication was osteoarthritis (64 CR: 65 MBK). The surgical approach was medial parapatellar in 65 CR and 63 MBK the rest were subvastus, patella resurfacing was not routinely employed. Pre-operative, intra-operative and post-operative data was collated.

Results: The body mass index was 32 ± 7 CR and 32 ± 6 MBK. The average age was 67 ± 8 CR and 67 ± 8 MBK. Pain in the contralateral knee was present in 79.7% CR and 74.3% MBK group. Minimum post-operative follow-up was one year. There was no significant difference in the pre-operative and post-operative fixed flexion contracture, 4.3 ± 5.4 to 1.0 ± 2.9 CR and 6.2 ± 6.9 to 0.9 ± 2.8. The mean flexion pre-operatively and post-operatively between the two groups was not significantly different 108 ± 19 to 105 ± 16 CR and 107 ± 15 to 102 ± 13. Patello-femoral joint symptoms diminished from 67% to 12% CR and from 69% to 21% in the MBK group. The dependence on walking aids diminished from 50.7% to 16.7% CR and 51.4% to 26.9% MBK. At one year, nine percent and 21% were dissatisfied in the CR and MBK groups respectively. In the CR group, two revisions had been performed, one for infection and the other for arthrolysis and poly exchange. Two revisions had been carried out in the MBK group, one for extreme ‘clunking’ and the other for arthrolysis with poly exchange.

Conclusions: The one-year results suggest that the levels of dissatisfaction and patello-femoral problems are significantly greater in the mobile bearing group as opposed the fixed bearing. The early results would not encourage the use of the mobile bearings. We await the long-term results as regards survivorship of the bearings.

Introduction and Aims: Private companies now offer risk assessment packages to hospital trusts. Data is collected using ICD coding and complication rates for individual surgeons are calculated and published. A risk assessment document was recently published at the Royal Gwent Hospital presenting complication rates and misadventures on league tables of specialty and consultants. Serious concerns were raised about the quality of the data.

Method: We undertook a study to independently evaluate the accuracy of data used to calculate these complication rates. Two orthopaedic surgeons with the highest published complication rates were studied. The notes of patients who had suffered complications were retrieved and the published complication data was compared with the clinical interpretation of the actual complication. One hundred and fifty reported complications were analysed.

Results: In most cases data accuracy was woefully inadequate (table 1). For example, revision procedures were counted as complications for the revision surgeon irrespective of who carried out the primary procedure. The normal work up of these patients, including procedures to investigate the presence of infection, are recorded as complications, with some patients being recorded as having up to four separate complications. Misadventures published for surgeons included dural tap during epidural anaesthesia.

Conclusion: The results of this study highlight the potentially devastating consequences of data inaccuracy. Inaccurate published data on complications, used to form league tables for individual surgeons can be career jeopardising. We advocate that consultation with the clinicians involved should always occur before data is published so that these inaccuracies can be picked up and the potentially damning consequences of falsely high complication rates can be avoided.

To identify any shoulder joint pathology on MRI of young patients (< 35 yrs) with a single simple antero- inferior dislocation of the shoulder at minimum 5-year follow-up.

Patients aged 16–35 years with a single antero-inferior shoulder dislocation with a minimum 5-year (range5–9 yrs) follow-up were identified. A history of recurrent dislocation or surgery excluded patients from study. Ethical approval was obtained and identified patients were asked to volunteer for clinical review and have an MRI scan. Shoulders were clinically examined, noting specifically any signs/symptoms of rotator cuff pathology or instability. All shoulders were imaged with a 1.5 Tesla open MRI scan to assess any pathology.

In a 5-year period (1994–1998), 349 patients sustained an antero-inferior dislocation. 251 were in patients aged 35 years or less. 136 of these were excluded either due to recurrent dislocations. 62 patients were lost to follow-up of 53 eligible patients 7 could attend for study. Only one patient had a positive anterior apprehension sign but he did not have any symptoms of instability in his daily activities or sport. The only abnormality demonstrated on MRI was of a united greater tuberosity fracture in one shoulder. The glenolabral and bicipitolabral complexes were normal in all shoulders imaged.

Bankart lesions, both bony and labral, are known to be associated with recurrent anterior shoulder dislocations.This study has shown no shoulder joint pathology on MRI at minimum 5-year follow-up in young patients who have sustained a single antero-inferior shoulder dislocation, confirming that labral pathology seems to be important in recurrent dislocations. Further study to image more patients is underway. These results indicate that acute imaging of dislocated shoulders may be useful to help predict young patients who are unlikely to re-dislocate and thus unlikely to require surgery.

We report a 72-year-old patient with thoracic myelopathy due to isolated ossification of the ligamentum flavum at T9-T10. Severe paraparesis had developed before the lesion was identified when thinning of a segment of the lower thoracic spinal cord was suspected on a second MRI examination. The diagnosis was then established by CT.