To identify the incidence and timing of superior subluxation following total shoulder replacement (TSR) and any associated change in pain, activities of daily living and ranges of movement. Forty-six TSR in rheumatoid patients with more than 5years follow-up were identified from a prospectively compiled database held by the senior author (ANS). Modified Constant scores (excluding the power component) were measured and recorded prospectively every 2years. Pre-operative and complete follow-up scores were available for 35 joints (27 patients). A Mann-Whitney U test was used to compare patients with subluxation and those without, with regard to the changes in the components of the Constant score at last follow-up compared with the pre-operative score. Superior subluxation of the humeral head was defined as when the lower third of the humeral head had migrated level or superior to the midpoint of the glenoid component as measured on the AP radiograph. An independent observer reviewed AP radiographs, taken at each 2 yearly review, at random with identity hidden and in no particular date order. Twenty-three patients developed superior subluxation since surgery, of which 87% occurred after 5years. Of the 35 joints with both clinical and radiological follow-up, 16 had evidence of subluxation. There was no statistically significant difference between the changes in the activities of daily living (Mann-Whitney U=106, p=0.1) and range of movement (U=140, p=0.7) components of the Constant score. However, patients without subluxation had a greater improvement in their pain scores (U=80, p=0.02). Approximately half of rheumatoid patients with TSR will demonstrate radiological changes of superior subluxation, in the majority after 5 years. This change is not associated with deterioration in activities of daily living or ranges of movement. However, pain relief persists irrespective of subluxation but is greater in those without subluxation.

To identify the incidence and timing of superior subluxation following total shoulder replacement (TSR) and any associated change in pain, activities of daily living and ranges of movement. Forty-six TSR in rheumatoid patients with more than 5years follow-up were identified from a prospectively compiled database held by the senior author (ANS). Modified Constant scores (excluding the power component) were measured and recorded prospectively every 2years. Pre-operative and complete follow-up scores were available for 35 joints (27 patients). A Mann-Whitney U test was used to compare patients with subluxation and those without, with regard to the changes in the components of the Constant score at last follow-up compared with the pre-operative score. Superior subluxation of the humeral head was defined as when the lower third of the humeral head had migrated level or superior to the midpoint of the glenoid component as measured on the AP radiograph. An independent observer reviewed AP radiographs, taken at each 2 yearly review, at random with identity hidden and in no particular date order. Twenty-three patients developed superior subluxation since surgery, of which 87% occurred after 5years. Of the 35 joints with both clinical and radiological follow-up, 16 had evidence of subluxation. There was no statistically significant difference between the changes in the activities of daily living (Mann-Whitney U=106, p=0.1) and range of movement (U=140, p=0.7) components of the Constant score. However, patients without subluxation had a greater improvement in their pain scores (U=80, p=0.02). Approximately half of rheumatoid patients with TSR will demonstrate radiological changes of superior subluxation, in the majority after 5 years. This change is not associated with deterioration in activities of daily living or ranges of movement. However, pain relief persists irrespective of subluxation but is better maintained in those without subluxation.

The National Institute for Clinical Excellence (NICE), in its “Guidance on the Selection of Prostheses for Primary Total Hip Replacement”, states that a revision rate of 10% or less at ten years should be regarded as the “benchmark” in the selection of prostheses for primary Total Hip Replacement (THR). This paper presents the results of such a study for primary Charnley THR. Methods: All patients undergoing primary Charnley THR during 1990 were prospectively registered with the Trent Regional Arthroplasty Study (TRAS). During 1990, 1198 Charnley THRs were performed on 1152 patients, under the care of 56 consultants, in 18 National Health Service and 6 private hospitals. The cohort contains 39.0% male and 61.0% female patients, with an average age at operation of 69.1years (21–103 years), 19.1% being less than 60 years. At 10 years all surviving patients at 5 years were registered with the ONS to ascertain living patients. These patients were contacted by letter to determine whether or not their THR had been revised. The status of the THR, for non-responding patients, was determined by contacting the patient’s GP through the Contractor Services Agency (CSA). The endpoint was defined as revision surgery to replace an original implant component. Results: At 10 years, the recipients of 438 THRs had died. The recipients of 89 THRs did not respond to the questionnaire at ten years. Implant status at ten years, in living patients was known for 671 of 760 (88.3%) THRs. The ten-year crude revision rate was 44 out of 1198 (3.7%) and cumulative survival rate was 95.5% (95% CI, 93.6% – 96.9%).

Conclusion: This is the first study to assess the survivorship at 10 years for primary Charnley THRs performed in the ‘general setting’ of the NHS as opposed to specialist centres and shows a result well within the NICE benchmark.

Cementless fixation for total knee arthroplasty (TKA) has been proposed as an alternative to cemented for several reasons, of which the most important is the possibility of increased survival. The purpose of this study was to compare the ten-year survival of TKA in a unique prospective randomised trial of cemented versus cementless fixation.

A consecutive series of patients was randomised to undergo either cemented or cementless Press-Fit Condylar (PFC®) TKA. There were 219 patients (277 TKA) in the cemented group and 177 (224 TKA) in the cementless group. There were no significant differences in age, gender or diagnosis between the two groups.

A single surgeon (PJG) performed or directly supervised all operations. The prosthesis used in all cases was the posterior-cruciate-retaining PFC® knee replacement system. Independent clinical review was performed at six months, annually until five years, and finally at ten years after surgery. Using revision surgery as the end-point, logrank analysis was used to compare the ten-year survival of the two groups.

The mean interval of follow-up was 6.3 years (range, 2.0–11.7). At the last review, 104 patients (138 TKA) had died, without need for revision. All patients were traced and there was no loss to follow-up. In the cemented group, seven arthroplasties were revised; five for infection and two for exchange of polyethylene inserts. Ten-year survival was 96.5% (95% CI, 90.9–98.7%). In the cementless group, six arthroplasties were revised; three for aseptic loosening, one for infection, one for instability and one resizing for anterior knee pain. The ten-year survival was 96.6% (95% CI, 89.6–98.9%). There was no significant difference in the survival of the two groups.

The long-term survival of cementless PFC® TKA is not significantly different from their cemented counterparts. The use of less expensive cemented implants, therefore, can make a significant impact on health resource planning.

The purpose of this study was to investigate the influence of ligamentous restraints on first metatarsal (MT1) movements in the context of hallux valgus (HV), the surgical correction of which relies on a sound understanding of factors leading to MT1 deformity. Hypermobility or instability of the first metatarsal at its tarsometatarsal joint (TMJ1) is associated with greater degrees of deformity and also greater risk of recurrence after surgery. Recent anatomical work has shown the importance of the plantar aponeurosis (PA), and the transverse ‘tie-bar’ system (TTB) of the metatarsophalangeal (MPJ) plantar plates and intervening deep transverse inter-metatarsal ligaments in the structure and function of the foot. These ligamentous systems are important in MPJ stability, but may also be important at TMJ1.

Ten normal cadaveric feet were dissected to expose the capsules and ligaments of the MPJs and TMTJs and the PA. They were then mounted in plaster of Paris leaving the MT1, MT2, and their articulations free. A loading fixture was constructed so that loads could be applied to MT1 in the transverse plane to produce moments in flexion, abduction or extension. The movements resulting from a load of 40N were measured relative to MT2 using an Isotrak II (Polhemus, US) magnetic measurement system. The tests were performed with the hallux mobile, fixed neutral and fixed dorsiflexed at the MPJ. After an initial test with all structures intact, the PA and the TTB were severed in random order and the test repeated. “Movement maps” were produced showing the range of motion available in different directions and with different ligamentous restraints.

Movement maps suggest that the TMJ1 behaves as a ball and socket joint with no preferred axis of motion. The contributions of the PA and TTB to stiffness in the sagittal plane are small (about 1° movement). However, the TTB provides significant control of the abduction of MT1. The control afforded by the TTB is particularly important since it can ensure that the PA acts to provide an adduction moment about the TMJ1. The integrity of these ligamentous structures is likely to be important in the success of corrective surgical procedures for HV, where disruption can allow up to 10° increase in MT1-2 angles.

We made a prospective study of the incidence of fatal pulmonary embolism in patients after total knee replacement with no prophylactic anticoagulation. There were 499 consecutive patients having 527 knee replacements. They all wore anti-thromboembolic stockings and were mobilised 48 hours after surgery. No patient was lost to follow-up. One patient died of pulmonary embolism 22 days after operation. There were no other deaths within three months of operation. The incidence of fatal pulmonary embolism was 0.19% (95% confidence interval: 0 to 0.6%). Fatal pulmonary embolism is rare after total knee replacement without prophylactic anticoagulation and the routine anticoagulation of these patients is of doubtful value.