Background: According to the mid-term results obtained from the previous registry-based studies, survival of cementless stems for aseptic loosening in younger patients with primary osteoarthritis has been better than the survival of cemented stems. However, it has not been clear if the endurance against aseptic loosening of cementless cups is comparable to that of cemented cups. The aim of the present study was to analyze population-based long-term survival rates of the cemented and cementless total hip replacements in patients under the age of fifty-five years with primary osteoarthritis in Finland.

Patients and Methods: Between 1980 and 2006, a total of 7310 primary total hip replacements performed for primary osteoarthritis in patients under the age of fifty-five years were entered in the Finnish Arthroplasty Registry. 4,032 of them fulfilled our inclusion criteria and were subjected to analysis. The implants included were classified in one of the three following groups: implants with a cementless, straight, proximally circumferentially porous-coated stem and a porous-coated press-fit cup (cementless group #1); implants with a cementless, anatomic, proximally circumferentially porous-coated and/ or hydroxyapatite-coated stem with a porous-coated and/or hydroxyapatite-coated press-fit cup (cementless group #2); and a cemented stem combined with a cemented all-polyethylene cup (the cemented group).

Results: Cementless total hip replacements, as well as cementless stems and cups analyzed separately, had a significantly reduced risk of revision for aseptic loosening compared with cemented hip replacements. The 15-year survivorship of cementless stem groups for aseptic loosening was higher than that of cemented stems (89% and 90% vs. 72%). The 15-year survivorship of cementless press-fit porous-coated cups for aseptic loosening was higher than that of cemented cups (80% vs. 71%). When revision for any reason was the end point in survival analyses, however, there were no significant differences among the groups.

Conclusions: Both cementless stems and cementless cups have better resistance to aseptic loosening than cemented implants in long term follow-up in younger patients. Even if liner-exchange revisions are taken into account, the long-term survival of cementless total hip replacements is comparable to that of cemented implants.

We have analysed from the Finnish Arthroplasty Register the long-term survivorship of the 12 most commonly-used cemented implants between 1980 and 2005 in patients aged 55 years or older with osteoarthritis.

Only two designs of femoral component, the Exeter Universal and the Müller Straight femoral component had a survivorship of over 95% at ten years with revision for aseptic loosening as the endpoint. At 15 years of the femoral and acetabular component combinations, only the Exeter Universal/Exeter All-poly implant had a survival rate of over 90% with revision for aseptic loosening as the endpoint. In the subgroup of patients aged between 55 and 64 years, survivorship overall was less than 90% at ten years.

The variation in the long-term rates of survival of different cemented hip implants was considerable in patients aged 55 years or older. In those aged between 55 and 64 years, none of the cemented prostheses studied yielded excellent long-term survival rates (≥ 90% at 15 years).

Introduction. A new interest for Metal-on-Metal (MoM) has risen worldwide. In Finland using of 28mm MoM bearings during the last years has gone up rapidly. MOM bearings in THAs are used more and more in Finland for young patients. We present short-term results of 136 MoM THAs.

Patients and methods. In our Department both 28 mmMetasul- (Sulzer) ja M2a (Biomet) systems have been used. Metasul Pressfit cementless monoblock cup has titanium net on poly cup with cobolt-chrome bearing and the stem used was cementless CLS. M2a system was performed using cementless Biomet Bimetric-stem and cemented Stanmore poly cup with cobolt-chrome bearing. This series consists of 129 consecutive patients and 136 hips operated on in our department during years 2000–2002.

Results. Mean age was 53yrs (20–73), BMI 27,0 (16,4–42,9). Indication was primary athrosis in 87, rheumatoid arthritis in 15, avascular femoral head necrosis in 12, dys-placia with secondary OA in 9, and other in 13. Hardinge approach was used 59 and posterior approach 77 times. Metasul was used 85 and M2a 51 times. Mean follow-up time was 20 months. Pre/postoperative HHS was 54 (23–97)/94(48–100). Leg length discrepancy 1–2,5 cm was noticed in 19 patients. 4 luxations occurred during the follow-up period. No thromboembolic or neurological complications occurred. In 5 operations peroperative fracture of trochanter major was noticed and fixed and in addition to that fissure of the femur was noticed in 5 cases; no signs of loosening was noticed in these. 2 cups had signs of loosening in all 3 zones, 11 cups in 2, and 19 in one zone. One femoral component had signs of loosening in all 7 zones, 2 in 2 zones, and 5 in one zone.

Discussion. Good MoM results from 1970s encouraged us to start again to use MoM THAs in our department. At the same time the trend to use modern MoMs is ascending in Finland. We want to follow these prostheses accurately and get the results quicker than from the national registry. Our series consists of relatively young patients. We can not draw any definite conclusions because of the short follow-up time, but it seems that there are not alerting signs at the moment that we could not continue using 28 mm MoM THAs.

Aims: The purpose of this study was to analyse the clinical and radiological results and revision rate of Oxford II unicompartmental arthroplasty in a community hospital setting. Methods: 46 unicompartmental arthroplasties were evaluated after mean 8.4-year follow-up. Clinical results were analysed according to Knee Society and Lysholm scores. Radiologically tibiofemoral axis and possible radiolucent lines were measured. Kaplan-Meier survivorship curves, using revision of any reason as an end point, were also analysed and compared to overall results from the Finnish Arthroplasty Register. Results: During the follow-up there were six revisions (13.0%): one of them for primary deep infection, menis-ceal bearing was repeatedly dislocated in one knee. Four conversions to TKA were made because of ongoing lateral osteoarthritis and an average time for revision surgery was 63.8 months (1,5- 120 months). The survivorship calculated at þve years was 90.5% (95%Cl 81.6–99.4; 33 cases at risk), and after eight years 87.6% (95%Cl 77.3–97,9; 19 cases at risk). Follow-up showed no clinical or radiological signs of solution of components.

The angle of tibiofemoral axis was also not altered signiþcantly during this observation period. Conclusions: We conclude that the unicompartmental Oxford arthroplasty is a potential alternative in the treatment of unicompartmental medial osteoarthritic knee. Indications and patient selection should be carefully considered. The survivorship was in accordance with most of the previous series.

Aims: Nationwide, computer-based survey of all total joint arthroplasties performed in Finland has been carried out since January 1980. From these records a cohort of 9,443 patients, with 80,734 person-years, after primary operation with a total polyethylene-on-metal knee arthroplasty (TKA) has been followed up for cancer. In 1999 we published the material until December 31, 1996. The standardized incidence ratio (SIR) for all cancers was 0.98. The SIRs for non-Hodgkin lymphoma (1.40), Hodgkinñs disease (1.24), multiple myeloma (1.54) and prostate cancer (1.49) were increased, but only that of non-Hodgkin lymhoma was statistically signiþcant 3 to 10 years after the operation. The overall cancer risk after TKA done for primary osteoarthrosis appeared to be negligible. Material and methods: Follow-up for cancer was undertaken using the þles in the population-based, nationwide Finnish Cancer Registry, employing personal identiþcation numbers. Follow-up for cancer started at the date of þrst knee replacement and ended on emigration, death, or 31 December 2000, whichever occurred þrst. No subject was lost to follow-up. Standardized incidence ratios (SIRs) were calculated by dividing observed numbers of cases by expected numbers. Results: There were 2,001 men and 7,442 women left in the cohort to be followed-up. Numbers of person-years are now 15,679 and 650,552, respectively. The mean duration of follow-up per person was therefore 8,5 years. During the 21-year follow-up period, 358 cases of cancer occurred in the male subjects. The expected number was 349. In the female subjects 801 cases of cancer were observed vs. 804 expected. Combining data for men and women, the SIR for cancer at all sites was 1.00. SIRs were signiþ-cantly lower in relation to cancers of the lung (0.69), and colon (0.77). The incidence of risk of colon cancer was lower than would have been expected only in women (SIR 0.70). As far as cancers of the urinary organs is concerned, the SIR was within unity (SIR 1,03). The overall incidence of non-Hodgkin lymphoma (extranodal sites included) was elevated, but without any statistical signiþ-cance (SIR 1.22). The SIR values for multiple myeloma and leucemia have reduced to 0.80 and 0.53. Conclusions: We conclude, that this large nation-wide material could not establish any association between TKA and the all-over incidence of remote or adjacent cancers; on the contrary incidences of certain cancers were in fact lower than those reported in the formed material with four years less follow-up. All the alarming SIRs in the former material, especially those with non-Hodgin lym-phoma, urinary tract cancers and leucemia, have now reduced and are less than unity.

Corrosion and wear of total hip (THA) and knee (TKA) prostheses extricate metallic particles and soluble metallic compounds. The oncogenic risk of these products should be known. Material and methods: Three Nordic cohorts of total hip (THA) and total knee arthroplasty (TKA) patients operated on for primary osteoarthrosis during 1967–1995 were combined for meta-analysis. The number of THA patients was 49,000 and TKA patients 24,000 totaling 497,000 person years. The mean follow-up time was 6.8 years. Standardized incidence ratios (SIRs) with 95% conþdence intervals (95% CI) were calculated for the observed and expected number of cancers. The expected numbers were based on national incidence rates. Results: The allover SIRs as well as the site-speciþc cancer incidences were similar for the THA and TKA patients. The observed number of all site cancers was 7639 and 8202 expected (SIR 0.93, 95% CI 0.91–0.95). The SIR for lung cancer (0.69, 0.64–0.75) was reduced. The incidence was also low for cancers of the stomach (SIR 0.76, 0.67–0.84), colon (SIR 0.86, 0.79–0.93) and rectum (SIR 0.89, 0.80–0.98). Slightly elevated SIRs were seen among TKA patients in cancer of the endometrium and prostate and among both THA and TKA patients in skin melanoma. Conclusions: Total cancer risk was signiþcantly reduced among THA and TKA patients due to decrease of respiratory and gastrointestinal cancers. The present results do not suggest any oncogenic risk of the components of hip and knee prostheses and their degradation products.

Aim: The HA coated Osteonics-Omniþt hip endoprosthesis with the PSL (peripheral self locking) acetabular cup was implanted in our institution between the years 1992 to 1996. This cup is spheric with several holes for screw þxation, and a Òwafße-likeÒ macrostructure along the periphery of the component. This component was connected with the HA coated Osteonics stem. Material and methods: A total of 173 patients (178 hips) mostly < 65 years old (average age, 50.5 years; range, 17–70 years) received a proximally HA-coated femoral prosthesis with a hemispheric metal-backed, HA-coated acetabular cup (PSL), with an average follow-up of 7,5 years (range 5 to 9 years). All operations were performed in the University Hospital by senior surgeons. There were 80 male and 86 female patients. The indications for operation were primary arthrosis in 84, secondary arthrosis (AVN, LPC etc.) in 34, rheumatoid arthritis in 34, posttraumatic in 13, and tumor in one case. This material compiles those cases revised for loosening of the acetabular cup (PSL). Results: Twenty-nine acetabular components have been revised due to the loosening and/or periacetabular osteolysis or access wear of the liner. Add to this there are 6 patients/hips on the waiting list. The total number of loose acetabular cups is therefore 35 (20%). The radiological signs of loosening have usually been evident with clear radiolucent lines (RLL) starting from the Gruen zone 3. At operation the cup have been loose with no signs of bony ingrowth and the HA coating resorbed away in most of the cases. There were no breakage of the screws. Survivorship analysis, based on those cases reported into the Finnish Arthroplasty Register, predicted a survival rate of 88.5% at four years (95%Cl 83.8–93.3, 93 at risk). Conclusions: The loosening rate of more than 20% with only 88.5% survivorship at four years is not acceptable. The bad results are mainly connected with the loosening of the PSL (peripherial self locking) type of acetabular component. The main features of that component are no porous coating, and the HA on the smooth surface. According to the literature and other Nordic implant registers the results with this kind of concept have been alarming. Theoretical disadvantages to HA coatings include the critical parameters required for its application on surfaces, and retrieval studies of implants at the time of revision indicate the potential concern for dissolution and delamination of the coating, especially on smooth metal surfaces. Also the manufacturer have changed the concept towards Ha on porocoating (Securþt). The clinical trials so far have focused on the performance of the femoral component the acetabular components have been of varying designs without any þrm conclusions. The results of this study do not indicate any signiþcant clinical advantage to the use of HA coated acetabular components in primary total hip arthroplasty.

Aims: The most common complications after total knee arthroplasty (TKA) are the result of patellar complications. The causes of patellar problems range from sub-luxation, dislocation, component loosening, rupture of the patellar tendon, excess wear of the polyethylene (especially after metal backing), retropatellar pain, and patellar fracture. The incidence of these patellar complications after TKA ranges from 5–30%. Selective retention of the patella has been recommended more recently although there are still potential problems of maltracking and anterior knee pain. According to the nationwide registration of all TKAs in Finland since 1980 it seems evident that interest of patellar retention during the primary operation has now been stabilized at the level of about 55 per cent. At the same time there are, however, quite a high incidence of reoperations done due to patellar complications or later resurfacing of the patella in connection of revisions done with other indications. Methos:

Database of the Finnish Arthroplasty Register was evaluated from the years 1999 and 2000 focusing on the reoperations done either due to patellar complication (in the notiþcation: indication for revision) or due to other reason (to be speciþed in full text). These were further divided into three main categories: removal or fracture of patellae, delayed resurfacing due to patellar pain or maltracking, and component loosening.

Conclusions: Reoperations done due to the patellar complications and/or later resurfacing of patellae mean quite a notable work-load; 31,7 to 33,6 per cent of all TKA revisions done in the years 1999 and 2000, respectively. Of the total of 113 delayed patellar resurfacing operations, almost 50 per cent were done in connection to revisions primarily due to other reasons, usually after excess liner wear. In conclusion we can say, that ÒprimaryÒ patellar complications (after patellar resurfacing in the primary operation) encountered about 15 per cent of all revisions, and those done in the Òsecondary phaseÒ (after retention of patella) another 15 to 16 per cent. This is in accordance with the results gained in the other Nordic Registers; in Norway ÒprimaryÒ/loose 16,5% of all TKA revisions. It seems that the need for a secondary patellar replacement in unreplaced cases was balanced by the need for revisions of failed patellar components in patellar replaced cases.

Aims: In 1999 we published a cohort of 24,638 polyethylene-on-metal total hip arthroplasty (THA) patients followed up for cancer, using Finnish Cancer Registry data, from 1980 to 1995. The number of person-years was then 173,022 (until 31st Dec, 1996). During follow-up, there were statistically significantly fewer cancers among the THA patients (standardized incidence ratio [SIR], 0.91; 95% confidence interval [Cl], 0.87–0.94). There was no significantly increased risk at any site, and for certain cancers that was even below the unity (lung and stomach).

On the longer run, however, certain tendency for increased risk for cancer of the urinary bladder, myeloma, and leukemia could be observed; SIRs were greater than unity with the THA patients followed up 3 to 9 years. Further follow-up of the cohort is therefore needed. Methods: The follow-up of the same cohort, originally identified in the National Register of Arthroplasties, maintained by the National Agency for Medicines (primary THA with primary arthritis as the indication) was expanded with a four year period (from 1st of Jan 1997 to 31st of Dec 2000). Follow-up for cancer was undertaken using the files in the population-based, nationwide Finnish Cancer Registry, employing personal identification numbers.

Follow-up for cancer started at the date of first hip replacement and ended on emigration, death, or December 31, 2001, whichever occurred first. Multiple cancers were taken account of in similar ways in relation to observed and expected numbers of cases. Results: After excluding revision and infective or systemic disease as indications for operation, there were 9,479 men and 15,157 women in the cohort followed. The updated numbers for person-years were 89,295 for males and 153,759 for females. The mean duration of follow-up was now 9,9 years. The total risk for cancer was now 0.93 (95%Cl 0.90–0.96) and that for stomach 0.89, for colon 0.90, lung 0.64, for urinary organs 1.01, and for connective tissues 0.88. The SIRs for non-Hogkin lymphoma, myeloma and leucemia were all under the untity, 0.88, 1.09 and 0.73, respectively, without any tendency for increased risk in the follow-up of plus ten years.

Conclusions: These findings indicate that the risk of hematopoietic cancers is not increased after THA using polyethylene-on-metal prostheses. Expanding of the follow-up with four years did not markedly change the profile of the SIRs at any specific site, and contrary to our earlier report there were increased risk left of myeloma and leucemia with increased follow-up time. The SIRs associated with soft tissue cancers and bone sarcomas were not significantly different from unity. No sarcomas developed at the site of a prosthesis.

Aims: Hallux valgus operations cannot always be carried out immediately due to long waiting lists. Effect of waiting for hallux valgus surgery has not been under investigation in a randomized controlled study. Methods: 209 consecutive patients (mean age 48 years, 93% female) with a painful hallux valgus were randomized in three groups: immediate operation or one year waiting time with or without foot orthoses. The follow-up period was 2 years. Main outcome measure was pain intensity during walking (VAS 0 to 100). Results: During the þrst year 64/71, 0/69 and 4/69 patients were operated in surgery, orthosis and no-orthosis groups, respectively, and during the two-year follow-up 66, 43 and 48, respectively. At one-year follow-up the pain was least intensive in surgery group. At two year follow-up the pain intensity was similar in all groups. The satisfaction with treatment was the best in the surgery group and orthosis group as was the fact also with the cosmetic disturbances. The total costs of care were similar in all groups. Conclusion: Immediate operation is superior to delayed operation or foot orthoses, as the beneþt from surgery is obtained already during the þrst follow-up year. If this, however, because of limited operative capacity is not possible, one year waiting, with or without orthois, does not jeopardize the results.

Aim: The purpose of this report was to analyse the clinical and survivorship results and revision rates of Bichat III uncemented total hip arthroplasty in a community hospital setting. Poor results are rarely published what may have effect on the results of meta-analyses done on hip replacement surgery. At the time of selecting the prosthesis there were no reports published on this particular model. Methods: Between 1987 and 1990 þftyþve patients (57 hips) were operated using the Bichat III endoprosthesis. The prosthesis has a ßuted, anatomic and non-porous Ti femur, and a threaded nonporous acetabular cup. There were 25 male and 30 female patients. Mean age of the male patients was 62 (40–75) and that for the female 61 years (43–82). The indication for operation was primary arthrosis in 45, posttraumatic arthrosis in 5, LPC in 2 cases, and rheumatoid arthritis, AVN and CHD one each. All the operations were made using the Hardingen approach. For the survivorship analysis the patients were traced from the Finnish Arthroplasty Register and Kaplan-Meir survival was calculated for all the 57 patients with the 95% Cl. Those not revised until 31st December 2001 were called for clinical and radiological examination. The mean follow-up time was 12,7 years (11,4–14,2). Results: During the follow-up 16 patients died (28%), and revision was done on 21 patients (37%) after a mean follow-up time of 7,2 years (3,6–11,3). Seventeen patients arrived to the clinical follow-up; of those only 10 cases were without any radiological signs of loosening. For all the patients re-examined the Mayo Clinics Hip Score was 50.8 in average ((5–75), and that for those with radiological signs of loosening 46,3 (16–71). The survivorship calculated at ten years was 57,0% (95%Cl 42,5–71,6; 22 hips at risk). Typical features at revision were total loosening of both components, marked metallosis and breakage of the polyethylene liner. Conclusions: Our results are in accordance with other reports with uncemented, non-porous coated components, as well as with those of the screw þxed acetabular cups. Also the reports from other Nordic arthroplasty registers speak favour of the non-acceptable results with such concepts of THA. Publication of also the negative results of THA may decrease risk of sc. publication bias. We conclude that until now there is sufþcient evidence that porous coating on both components of hip endoprosthesis is crucial for reliable þxation of uncemented components. Prosthesis selection should be made on a well documented basis and trials should be made in arthroplasty centers and on a prospective and randomized basis.