Total hip arthroplasty is well established as a successful treatment modality for end stage arthritis, with a variety of components currently available. However, utilising traditional stemmed implants in patients with distorted proximal femoral geometry can be technically challenging with increased risk of complications.

We present seven patients with distorted proximal femoral anatomy or failed hip arthroplasty in whom a technically challenging primary or revision operation was simplified by use of a Proxima stem. This is a short, stemless, metaphyseal loading implant with a pronounced lateral flare.

At twelve months follow up there have been no complications with average improvement in Oxford and Harris scores of forty and forty-nine respectively. Radiological analysis shows all stems to be stable and well fixed.

Designed primarily as a bone conserving implant for primary hip arthroplasty we propose that the Proxima prosthesis also be considered in cases where a conventional stemmed implant may not be suitable due to challenging proximal femoral anatomy. The use of the stemless Proxima implant provided a simple solution in seven difficult and potentially lengthy complex primary and revision hip arthroplasties with gratifying clinical and radiological outcomes.

Introduction: A composite femoral stem was introduced with a structural stiffness similar to that of the native femur to promote proximal load transfer. This consisted of a cobalt-chromium alloy core surrounded by an injection-moulded layer of polyaryletherketone covered with a porous titanium mesh.

Materials and Method : 31 primary total hip replacement stems were implanted in 26 patients with an average age of 37 years (range 17–57) using the Epoch Stem (Zimmer, Warsaw, IN) as part of a prospective multicentre trial. A cementless Harris-Galante I acetabular component with a 28mm polyethylene insert was used in 28 cases, a Plasma cup (Aesculap) in 1 case and a bipolar head in 2 cases. Annual follow-up using Harris Hip Scores and radiographic evaluation was performed for a mean of 10.1 years.

Results: Harris Hip Scores improved from a mean of 56 points preoperatively to 90 at the time of last follow-up. Radiographs showed no stem migration or loosening. 4 cases with polyethylene wear showed trochanteric osteolysis. Specific radiographic features noted were calcar rounding in 10 cases and improvement in calcar appearance with squaring in 4 cases. Calcar resorption was seen in 1 case associated with polyethylene wear. There have been 9 instances of revision of the head or acetabular component – 3 liner exchanges for polyethylene wear, 3 liner exchanges for dissociation, 1 acetabular component revision for infection and 2 bipolar heads revised to unipolar heads with cementless acetabular component for pain. No stem has required or requires revision.

Discussion: The Epoch stem resulted in an excellent clinical outcome, with evidence of radiographic stability and proximal bone preservation, and no cases of stem revision in a small cohort of young patients at 10-year follow-up. The limitation of reconstruction in this cohort of young patients has been the acetabular component.

Introduction: Correct prosthesis alignment and joint line reproduction in total knee replacement (TKR) is vital for a successful clinical outcome. It is acknowledged that the ideal coronal alignment of the knee following TKR should be between 4–10 degrees of valgus. A neutral or varus knee is associated with a higher failure rate. Previous studies have shown that ideal alignment is achieved in only around two-thirds of cases.

Joint line elevation > 8mm has been associated with inferior clinical outcome, and depression associated with retropatellar pain and increased risk of patella subluxation.

Recently, modifications have been made to the Kine-max-Plus Total Knee System instrumentation, theoretically providing better internal fixation to prevent a varus cut and a 12 mm measured resection from the “normal” tibial plateau. This study aims to examine whether these changes result in an improvement in alignment, and a more reliable restoration of joint line.

Materials and Methods: Two consecutive series, each of 75 patients who had undergone TKR using either the old (Group A) or the new (Group B) instrumentation were included in the study. Antero-posterior and lateral preoperative and postoperative knee radiographs were assessed using the American knee society radiographic analysis for prosthesis postionoing by 2 independent observers. The Tibial and Femoral Component Angles in the coronal plane (cTCA and cFCA) and in the sagittal plane (sTCA and sFCA) were measured, as was the change in joint line height.

Conclusion: Our results suggest that use of the new instrumentation is associated with better restoration of joint line, and is more effective in preventing implantation of the tibial component in varus. These figures relating to a modern instrumentation system provide a yardstick against which computer assisted and robotic surgery can be judged. Long-term follow-up will be required to assess the clinical significance of these results.

In the future, registration with a surgical speciality may require no more than the demonstration of core knowledge in the generality of that speciality and in the diagnosis and management of the related acute conditions. Sub-speciality training will be recognised separately. Rationalisation of referral patterns would then require that primary care practitioners are aware of these special abilities.

A questionnaire was sent to 1207 General Practitioners in the Avon, Leicestershire and Central London regions. The response rate was 86.2% (n = 1040). Views were sought on the management and referral of patients experiencing problems with existing hip replacements. These included the use of pre referral radiographs, whether practitioners would preferentially refer to a specialist hip surgeon and whether they believed that referral to a generalist could compromise patient care.

The majority GP’s arranged pre referral radiographs (84.2%). A third (34.2%) indicated that they would refer to any orthopaedic surgeon. 50.0% felt that outcome could be compromised if the patient was seen by an orthopaedic surgeon without a special interest in hip surgery.

There appears to be a need for more scientific information for GP’s and an agreed referral protocol. It is expected that rationalisation the referral system would lead to closer matching of patients needs with specialists’ abilities.

Introduction: The CPS-Plus cemented, collarless, polished stem, is a double-taper design with rectangular cross section. An additional proximal stem centraliser ensures optimal alignment of the stem and an even cement mantle and has been shown to increase cement pressurisation during insertion.

Guidelines from the National Institute of Clinical Excellence (NICE) recommend comparative clinical evaluation for prostheses without long-term follow-up data and set an initial ‘benchmark’ for performance at 3 years.

Data collection for the CPS-Plus stem is on-going as part of a multi-centre prospective clinical trial. 227 patients have been recruited to the trial and 70 of these have reached 3 years follow-up.

Method: Patients were recruited to the study by surgeons working at three centres in the UK and two in Norway. Patients were fully evaluated pre-operatively. Operative details, post-operative course and follow-up visits at 3, 6, 12, 24, and 36 months were recorded. Postoperative clinical progress was monitored using recognised scoring systems and radiographic assessment.

Results: The mean Harris hip score (0 – 100) improved from 42.7 pre-op to 91.6 at 6 months and 95.8 at 3 years. The mean Merle d’Aubigne and Postel score (0 – 18) improved from 8.55 pre-op to 16.09 at 6 months and 17.08 at 3 years. The mean Oxford hip score (60 – 12) improved from 41.6 pre-op to 14.1 at 3 years. Radiological subsidence at 3 years is less that 1.5mm in 97% of patients and less than 3mm in the remainder. From all 227 implants, there has been one revision for deep infection. There have been no cases of aseptic loosening. Other significant complications include one peri-prosthetic fracture and 4 dislocations, but these were not thought to be related to the design of the implant.

Discussion: The early results of the CPS-Plus femoral stem are encouraging and the prosthesis achieves the 3-year benchmark set out in the NICE guidelines, with a zero revision rate in the first 70 patients recruited to the trial. The prosthesis shares many design features with other well-established collarless, polished, tapered stems. The ease of accurate insertion and improved cement pressurisation resulting from its unique design features should ensure excellent medium to long-term outcome. The multi-centre clinical trial will continue to monitor progress.

We hypothesise that patients are unable to recall much of the information imparted during the informed consent procedure. This may have important medico-legal consequences and increase patient anxiety. Receiving the information in a written format may improve patient recall. There have been no previous studies testing recall or information sheets for British orthopaedic patients.

We performed a randomised controlled trial of consent for total hip arthroplasty, with one group of patients receiving a written information sheet with explanation as necessary, and the control group receiving the same information verbally. The consent was obtained at a pre-operative assessment clinic approximately three weeks before admission. On admission, a questionnaire was filled in both groups of patients to assess recall.

There were no significant differences between the two groups with regard to type of arthroplasty (revision or primary), age, or days from consent to admission.

The group receiving written information performed better in the recall questionnaire. This group were pleased to have received the information sheet, there were no negative comments about the sheet. In the group who received verbal information, most expressed a desire to receive a written information sheet. One patient stated that she would rather know nothing about the operation and would have refused a sheet. We conclude that patient information sheets are an acceptable and appropriate method of imparting the necessary information for informed consent for total hip arthroplasty, and are more effective than standard verbal informed consent.

Medico-legally, the sheet could be a permanent record of what was discussed. This should prevent disputes and claims due to poor recall of the consent procedure.