Background: Poor results were observed at medium term follow-up (FU) after first and second generation cementless stems implantation in total hip arthroplasty (THA). Revision rate up to 24% is reported with anatomic stems; stress-shielding rate up to 50%, thigh pain rate up to 21%, loosening rate up to 20% and osteolysis rate up to 29% were reported with cylindrical stems. A third generation tapered stem, the Synergy stem, was introduced in 1996 to rise such weakness points.

Material and methods: A retrospective, cohort study was carried out in two academic centers (London, Toronto, Canada & Rome, Italy) on 232 primary THA in 215 patients with a 10 to 12 yrs FU. Mean age at surgery was 60 yrs (18–82), 95 patients were males and 120 females. Thirty-six patients were lost at FU (13 died before the 10 yrs mark, 22 changed residency, 1 not willing to be seen) with no problems related to the replaced hip. Remained at FU 196 THA. Patients selection: Dorr type A and B femurs suitable for receive a Synergy stem. Its characteristics are the following: Ti-6Al-4V, straight, tapered, 3D wedge cross-section, proximal antirotational fins, low-profile neck, neck angle 131°, metaphyseal part porous or HA coated, diaphyseal part grit blasted, polished tip, surgeon-friendly ancillary instruments. Clinical results of the 196 THA with more than 10 yrs of FU were assessed preoperatively and postoperatively at 5 and 10 or 11 or 12 yrs by means of standard evaluation tools: SF12, WOMAC and Harris Hip Score. Thigh pain frequency and intensity were also scored. Radiographic analysis was focused on stem alignment, bone ingrowth, radiolucent lines presence, width and progression, stress-shielding, heterotophic ossification (HTO). Student paired test and Kaplan-Meier survival analysis were used for statistical analysis.

Results: All clinical evaluation tools showed both at 5 years FU and at latest FU (10–12 years) a statistically significant (p=0,001) improvement compared to the preoperative scores. We observed a not constant thigh pain in 7 patients (5,5%). Nineteen patients (10%) underwent evision due to polyethylene wear (6 cases), late periprosthetic fracture (5 cases), subsidence (2 cases), instability (3 cases), infection (3 cases). Cumulative survival rate was 97% at 2 and 5 years, 90% at 10 years. Stem related revisions were the 2 cases of subsidence, both related to occult intraoperative calcar crack and early revised (within 1 year); cumulative stem-related survival rate at 10 years was 99%. Alignment was varus in 9 cases and valgus in 3. Bone in-growth was observed in 194 patients (98%). Radiolucent lines were uncommon, non progressive, less than 2 mm, in Gruen zones 2 and 6. Stress-shielding was present as cortical reaction in 5 femurs in Gruen zones 3 and 5. Thirty-four cases of HTO (grade I and II in 27 case and grade III in 7 cases) were observed.

Conclusions: The Synergy stem demonstrates excellent clinical and radiographic results at 10–12 yerars FU in 196 patients. Survivorship (with stem revision as end point) is 99% at 10 years. Thigh pain is uncommon and the level of activity and autonomy is excellent. Radiographically bone ingrowth is evident in all stems and radiolucent lines are “benign” with no aseptic loosening. Attention must be paid at the moment of stem press fit insertion to avoid occult proximal femoral fractures that may require revision surgery.

Introduction: This paper presents the short term results of 56 (28 males and 28 females) consecutive Unicompartimental Knee Arthroplasties (UKAs) and 54 (29 males and 25 females) High Tibial Opening Wedge Osteotomies (HTOs), performed in two centres (Toronto-Canada and Torino-Italy), between 2001 and 2004.

The aim of this prospective study was to compare UKAs to HTOs, in terms of clinical and functional Results: Materials and Methods:

In all UKAs we implanted an Accuris prosthesis (Smith& Nephew, Memphis TN), in all HTOs we performed a medial opening wedge osteotomy, according to the surgical technique and syntesized with a Puddu Plate (Arthrex, Naples FL).

We evaluated all patients preoperatively and at 6 months postoperatively, at 1 year, 2 years and at the last follow-up visit (mean 3,5 years for UKAs and 2,5 years for HTOs), using the Knee Society Score (KSS) and the WOMAC (Western Ontario and McMaster Universities) Score.

Results: The mean age at operation was 55 years for the HTO group and 65 years for the UKA group.

Postoperative program for the HTO group was: 4 weeks of CPM (continuous passive movement), partial weight-bearing al 4 weeks (30–50% of body weight) and then full weight-bearing at 8 weeks postoperatively.

In the UKA group, full weight bearing was allowed immediately after operation.

We observed only one significant complication postoperatively: an early infection in an HTO patient. We thought this complication was not related to the treatment chosen, but to external factors, so we decided to exclude this patient from our study.

In the HTOs group, the KSS knee score (KS) and function score (FS) improved from respectively 38 and 55 preopertively to 76 and 91 at the final follow-up evaluation, while in the UKA group KS increased from 43 to 93 and FS increased from 50 to 84.

The WOMAC Score improved from respectively 48 (HTO Group) and 45 (UKA Group) preoperatively to 15 (HTO Group) and 14 (UKA Group) at the final follow-up evaluation.

Discussion and conclusion: According to both scores (Womac and KSS), the two groups did not differ significantly at 1 year, 2 year and last followup evaluation, considering the different ages of the patients (55 years of the HTO Group versus 64 years of the UKA group).

Comparison of study groups shows good outcome at early and mid-term follow-up. All patients had scores rated good to excellent (both KSS and WOMAC).

However, we found a little difference in KSS between the two groups: UKAs have a higher Knee Score (better knee assessment), while HTOs have a significantly higher Functional Score (better performances, maybe due to a more “anatomic saving” procedure).

This data suggests that the UKAs have better knee assessment, meanwhile the HTOs have better function. Given that, both treatments lead to a good to excellent outcome at early followup.

In 33 dogs we implanted femoral stems made either of carbon composite, some coated with hydroxyapatite, or of titanium alloy with a porous coating. Osseointegration was greater in the hydroxyapatite-coated than in the un-coated stems (p less than 0.001). Push-out tests, at an average of 7.2 months after implantation, showed a six-fold increase in interface shear strength and a twelve-fold increase in shear stiffness in the hydroxyapatite-coated group compared with noncoated implants. The highest shear-strength values were found in the porous-coated titanium alloy stems, around which there was also the most resorptive bone remodelling.

The purpose of this study was to determine the biological effects of the elastic modulus of the femoral stem in canine hip arthroplasty. Cementless total hip arthroplasty was performed in 12 dogs, six had a low elastic modulus polyacetal resin stem and six had a high modulus stainless steel stem. The components were otherwise similar. At six and 12 months after operation, radiographic and histomorphometric analysis showed that those with steel implants had more cortical porosity than did the other group (p less than 0.01). We suggest that the elastic modulus of the implant is an important factor in controlling cortical bone resorption. A low modulus femoral prosthesis can significantly decrease bone resorption which might otherwise eventually lead to implant failure.

We reviewed the results of 277 intertrochanteric valgus-extension osteotomies performed between 1973 and 1975 for primary or secondary osteoarthritis. The average age of the patients was 51 years and follow-up varied from 11 to 15 years. At the latest evaluation 67% of the hips were good or excellent on the Merle D'Aubigne scale. Better results were obtained in patients under 40 years of age with unilateral involvement and a mechanical (secondary) aetiology. An elliptical femoral head, minimal subluxation and an adequate pre-operative range of motion were also favourable. There was radiographic evidence of regression of the arthritic changes in 39% of the hips at final review. Valgus-extension osteotomy is effective for secondary osteoarthritis of the hip in selected younger patients, but not for those with primary hip disease or a poor range of movement.

We have reviewed the results of 106 intertrochanteric osteotomies performed for osteonecrosis of the femoral head. The average age at operation was 47.5 years. At two years from operation 71% of the hips had a clinically satisfactory result and at final follow-up, an average of 8.2 years after operation, 58% continued to have excellent or good rating. Twenty-four hips had needed total replacement or arthrodesis because of pain. Patients aged less than 55 did better than those operated on after that age, and hips with an idiopathic or post-traumatic aetiology did considerably better than alcohol-induced or steroid-induced cases. In view of these findings we believe that in the younger adult, in the absence of metabolic bone disease or advanced joint destruction, intertrochanteric osteotomy should be considered for the treatment of osteonecrosis.

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed.