The aim of this study was to report the procedure survival and patient-reported outcomes in a consecutive series of patients <50yrs at the time of hip arthroplasty with a metal-on-metal hip resurfacing system who have progressed to a minimum of 10yrs follow-up. Patients presenting for treatment of degenerative conditions of the hip electing to undergo hip resurfacing were included in a clinical registry (N=226 patients; 238 procedures). Procedure survival was confirmed by crosschecking to the Australian Orthopaedic Association National Joint Replacement Registry and comparing to all procedures by other surgeons nationwide. Kaplan-meier survival curves with 95% confidence intervals were constructed, while patient-reported outcome measures were compared with t-tests and postoperative scores assessed with anchor analysis to age and gender-matched normative data. At mean follow up of 12 years, six cases were revised with a cumulative survival rate of 96.8% (95%CI 94.2–99.4) at 15 years. Majority of revisions were early (<3yrs) and occurred in females (N=4). Patient-reported general health, disease state, hip function and activity level maintained large improvements beyond 10 years post-implantation and were equal to or exceeded age and gender-matched normative data. Metal-on-metal hip resurfacing in males and females aged <50 years at time of surgery demonstrated a high rate of cumulative survival beyond 10 years follow up. The results demonstrate excellent outcomes in this age group.

The Birmingham hip resurfacing (Smith & Nephew, Tennessee) (BHR) has been used in younger more active patients.

Aim

Adverse tissue reactions have been a concern in relation to metal components, particularly in hip replacements. We look at a possible correlation between hip joint effusion and metal ion levels.

There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach.

This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterized as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals.

A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years.

Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.

Introduction

Dissatisfaction with the posterior approach to total hip replacement has led to the anterior approach being adopted with enthusiasm in some areas.

Introduction

The observation of elevated heavy metal ions in arthroplasty patients in association with complications has led to concern on the part of patients and surgeons. The aim of this study was to determine the levels of cobalt chromium ions in three compartments, the joint fluid, plasma, and CSF.

Background and purpose

To identify methods used to measure free living sedentary behaviour in people with back pain and review the validity and reliability of identified measures.

Comparisons of blood metal ion levels of cobalt and chromium (CoCr) between metal-on-metal total and resurfacing hip arthroplasties are limited. High levels of CoCr may result in long-term adverse biological effects. We compare metal ions levels between total and resurfacing implants.

70 patients (28 males and 42 females) had a total hip arthroplasty using the Birmingham (Smith & Nephew) modular femoral component and a variety of stems, articulating with the Birmingham resurfacing component. The average age was 65.5 (±6.8) years and an average follow-up of 6.0 (±2.2) years. 170 patients (145 male and 25 female had a Birmingham resurfacing arthroplasty with an average age of 54.7 (±9.9) years and an average follow-up of 5.9 (±3.0) years. CoCr levels were measured. Bivariate correlations and independent samples t-tests were applied to determine similarities and differences within and between groups.

Average ion levels in total arthroplasty patients were: Co 114.17 (±94.01) nmol/L (range 2–414); and Cr 75.12 (±68.45) nmol/L (range 10–312). Average levels in hip resurfacing arthroplasty were: Co 55.98 (±79.5) nmol/L (range 7–505); and Cr 70.77 (±87.41) nmol/L (range 5–751). Both total and resurfacing groups showed significant correlations (p<0.01) between Co and Cr levels. A significant difference was observed between the total and resurfacing group Co levels (p<0.0001). No significant difference was shown between group Cr levels (p>0.672).

The average total hip replacement CoCr levels were higher than the hip resurfacing levels. While the overall activity level may be higher in the resurfacing group, possibly the incidence of stop/start frequency may be higher in the total hip replacement group.

Hip resurfacing arthroplasty average CoCr levels are lower than those of total hip replacement patients. Associations between Co and Cr metal ion levels are shown within each group. Co levels differ significantly between groups where Cr does not. Long-term follow-up of CoCr levels are required.

The Repicci modification of the Marmor unicompartmental arthroplasty (UKA) has provided a minimally invasive alternative to proximal tibial osteotomy for localised osteoarthritis. Advantages of UKA include preservation of bone, faster rehabilitation and maintained function. This study analyses the survivorship of the Repicci medial compartment arthroplasty with a minimum 10-year follow-up.

438 medial UKR procedures were performed between 01/01/1998 and 01/07/2001 included 68 bilateral procedures in 370 patients. The patients comprised of 229 males and 141 females. A specific set of selection criteria were used, including clinical, radiological, an arthroscopic data. The average age at operation was 66.7 years. The average follow-up was 12.8 years. For the patients who are not reachable, we sought the help of the Australian joint replacement registry. All revisions were identified. Procedures were reviewed to determine survivorship and function. Clinical outcomes scores of SF36v2. WOMAC and Oxford Knee were analysed at pre-operative, 1, 3, 5 and 10 year intervals.

In 54 patients (64 procedures) the implant was in situ at the time of death. Revision was carried out in 37 knees (8.5%) at a mean time period of 7.8 years (1–13) post-operatively. Of the revisions, the commonest cause was progression of arthritic changes in the lateral compartment, 25 patients. Loosening of the tibial component was present in six patients and for six patients whose data was obtained from the registry, revision was documented, but no cause was identified. Kaplan-Meier investigation showed survivorship of 91.6% to 12.5 years. Average pre-operative, 1, 3, 5 and 10 years SF36v2 Total scores were 107.80, 124.57, 124.83, 111.14 and 121.47. WOMAC Total scores for pre-operative, 1, 3, 5 and 10 years were 51.96, 83.34, 80.59, 82.00 and 78.54. Oxford Knee scores for pre-operative, 1, 3, 5 and 10 years were 35.76, 20.99, 19.28, 19.61 and 21.16.

Significant differences (p<0.0001) were observed between all pre-operative and post-operative 1, 3, 5 and 10 year outcomes of SF36v2, WOMAC and Oxford Knee scores.

UKR is an operation which is often regarded as a temporising procedure, on the way to a total knee replacement, the attrition rate is less than 1% per year, indicates that long-term function is a goal which may be achievable.

UKR provides satisfactory function, with a low revision rate, and a minimally invasive approach does not decrease the efficacy, while currently, improving function, speed of recovery, and patient satisfaction. Patient selection, particularly in relation to the status of the lateral compartment articular surface may be an important aspect in minimising revision incidence.

The Birmingham mid-head hip resurfacing arthroplasty (Smith & Nephew, Tennessee) (BMHR) is designed for use in patients with avascular necrosis of the femoral head. The BMHR has limited short-mid term follow-up results. We report the experience of 27 consecutive BMHR procedures with a minimum two year follow-up.

23 patients (20 males and 3 females) with an average operation age of 49.8 years (SD ±10.9) (22–65) were investigated. The mean follow-up period was 3.0 years (SD ±0.77). The operations were between April 2008 and November 2011 by one surgeon. Data and outcome measurements were collected prospectively and analysed retrospectively. Procedures were reviewed to determine function. We evaluated Harris Hip Scores, Short Form-36 (SF-36v2) Scores, Tegner Activity Score Scores and McMaster Universities Osteoarthritis Index Scores (WOMAC) comparatively at preoperative, six month and yearly intervals. Paired samples t-tests were applied to determine improvements where p<0.05 was deemed as significant.

There were no patient deaths. There were no revisions. Harris Hip scores for pre-operative 6, 12, 24 and 36 month intervals were: 52.30, 84.14, 83.07, 87.50 and 89.50. Average pre-operative 6, 12, 24 and 36 month SF36v2 Total scores were: 116.54, 124.32, 130.44, 135.97 and 133.18. Tegner scores for pre-operative 2.75, 3.29, 3.00, 3.67 and 3.01. WOMAC Total scores for aforementioned intervals for the posterior approach were: 59.51, 84.22, 90.30, 86.86 and 92.25.

The mean Harris Hip scores improved significantly between preoperative and 6, 12, 24 and 36 months (p<0.001). The mean SF-36v2 physical scores improved significantly between preoperative and 6, 12, 24 and 36 months (p<0.016). WOMAC scores improved significantly between preoperative and 6, 12, 24 and 36 months (p<0.017).

The presence of avascular necrosis significantly increases the revision rate for hip resurfacing surgery. The BMHR prosthesis, in this short term follow-up, appears to avoid the main cause of failure, femoral component loosening. Longer term efficacy remains to be seen. We plan to continue close supervision of these patients.

The Birmingham Hip Resurfacing (BHR) has been used in the younger more active patient for the treatment of advanced osteoarthritis. Long-term follow-up of the BHR is limited. The Australian national joint replacement registry shows that failure rates vary greatly, depending on implant types. 77 consecutive BHR procedures with a minimum ten year follow-up are reported.

There were 70 patients (44 males and 26 females) with an average operation age of 57.4 years (SD ±12.6). All patients were evaluated, including the “learning curve” patients. The mean follow-up period was 11.42 years (SD ±0.50). The arthroplasties were performed between April 1999 and December 2000 by one surgeon, with a standardised patient selection set of criteria. Data and outcome measurements were collected prospectively and analysed retrospectively. We evaluated Harris Hip Scores, Short Form-36 (SF-36v2) Scores, Tegner Activity Score Scores and McMaster Universities Osteoarthritis Index Scores (WOMAC) comparatively at preoperative, six month and yearly intervals

In 8 patients (10 procedures) the implant was in situ at the time of death. Revision was carried out in 6 hips (7.8%) at a mean time period of 2.5 years (0–10) post-operatively. Failure was due to femoral neck fracture in four patients, acetabular loosening in one and avascular necrosis of the femoral head, leading to loosening, in one patient. Kaplan-Meier analysis showed survivorship of 92.2% to 10 years. The mean Harris Hip scores (paired t-test, p<0.05) improved significantly from 59.7 preoperatively to 80.1 at ten years. The mean SF-36v2 physical scores (paired t-test, p<0.05) improved significantly from 35.09 preoperatively to 47.83 at ten years. WOMAC scores (paired t-test, p<0.05) improved significantly from 54.61 preoperatively to 85.89 at ten years.

The BHR prosthesis, in this series, has been shown to be effective, reliable, and durable in this group of highly active, relatively young patients. Problems with metallic debris, sensitivity reactions, and osteolysis have not been seen. However, we believe that with better selection criteria, improved understanding of component positioning and surgical techniques, results can be improved.

There is a report that higher failure rate in uncemented total knee replacement components due to loosening. However, uncemented fixation has been an attractive concept because of bone preservation and revision surgery, potential improved load transfer, and decreased surgical time. “Regenerex” is a porous titanium layer with excellent initial fixation, and the promise of providing favourable biological fixation. This is used with the Biomet Vanguard total knee replacement.

14 patients had undergone total knee replacement surgery comprising 11 men and three women with an average age of 63.07 years, and a body mass index of 30.33. Three of these patients required revision, because of tibial component loosening within 12 months of surgery. There were two men and one woman with an average age of 63.33 and BMI of 34.55. Clinically, patients developed pain and a gradual deformity as a result of a symmetrical collapse of the proximal tibial bony support surface.

Histopathology on the removed specimens shows the development of fibre cartilaginous metaplasia with evidence of necrotic bone. This was similar in all patients. There was no foreign body giant cell reaction, and no evidence of infection. The appearance was suggested of osteonecrosis, occurring gradually.

The incidence of frequency of this complication with this component in our experience is of concern, and the aim of this presentation is to determine whether this is a more widespread phenomenon.

There has recently been an increase in the number of hip replacement procedures performed through an anterior approach. Every procedure has a risk profile, and in the case of a new procedure or technique it is important to investigate the incidence of complications. The aim of this study is to identify the complications encountered in the first 100 patients treated with the minimally invasive anterior approach.

This is a case series of the first 100 hips treated and were assessed for complications. These were classified according to the severity and outcome [1]. The 100 hip comprised of 98 patients; 46 males and 52 females with an average operation age on 70.1 (±9.38) years. There were 2 bilateral procedures. Specific patient selection criteria were used. All complications occurred within one month of surgery. Complications such as fracture, deep vein thrombosis (DVT), cup malposition, femoral stem malposition, retained screw, excessive acetabular reaming and skin numbness were noted. Complications associated with fracture were characterised as either periprosthetic or trochanteric. Clinical outcome scores of SF36v2, WOMAC, Harris Hip and Tegner activity score were analysed at pre-operative, 6 months, 12 months 24 months and 36 months intervals.

A total of 13 early complications occurred. Of these 13 complications the most common complications were trochanteric fracture, 3 instances (3.00%), periprosthetic fracture, 2 (2.00%), DVT, 2 (2.00%), numbness, 2 (2.00%) and loosening. Other complications recorded were cup malposition, 1 (1.00%), femoral stem malpositon, 1 (1.00%), retained screw, 1 (1.00%) and excessive acetabular reaming, 1 (1.00%). All fractures occurred in patients over the age of 60 years. There were no dislocations.

Significant differences (p<0.05) were observed between all clinical outcomes measures pre-operatively and postoperatively (6, 12, 24 and 36 months). The unfamiliarity of the approach, however, increased operating time, and exposure problems, lead to trochanteric fracture.

Background

Exercise can be effective in treating Chronic Low Back Pain (CLBP) (Hayden et al 2005). Pilates-based group exercise programmes may be useful in the treatment of CLBP.

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests.

The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88).

The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%).

Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°).

Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03.

An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome.

Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis).

Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology.

The aim of the study was to develop a simple and effective method of determining acetabular component ante-version at the time of surgical implantation. A technique using a laser beam was developed, and put into practice.

Ante-version and closure of the component determine the three-dimensional position. Ante-version is particularly difficult to judge because of lack of perspective from the surgeons position. Using a standard industrial laser, a protractor and a tripod, a beam is projected across the operative field, allowing the acetabular impactor handle to be lined up, at predetermined angle. The patient needs to be positioned accurately preoperatively, and secured in a stable fashion to the operating table. The operating table needs to be parallel to the floor.

We have found this technique easy-to-use. It is less invasive than the computer navigation techniques requiring skeletal fixation, but it does not provide as much information. It is simple, inexpensive, easily transportable. As far as anteversion measurement is concerned, because of the longer distance of projection it provides a greater degree of confidence in alignment, than the standard short jigs which attach to the handle of the acetabular impactor.

Pain relief in hip arthroplasty plays an important role in the intra/post operative stages in order to achieve an almost pain free post operative recovery period to mobilise the patient as early and safely as possible and avoid undesirable post surgical complications.

A consecutive series of 99 total hip arthroplasties in 93 patients performed by a single surgeon between December 1996 and January 2006 were assessed for signs of clinical or radiological loosening.

Intra-operative local anaesthetic mixture (Ropivacaine-Ketorolac (30mg) -Adrenaline or RKA mixture) was infiltrated into the joint capsule and surrounding tissue around the acetabular component, and into the different muscle layers in the thigh around the femoral component. A total of 150–200 mls of this mixture was injected and a further 50 mls (with 30mg ketorolac) injected through a catheter left in-situ before discharge 12 to 24 hours later. Radiographic analysis was carried out using the Hodgkinson criteria to predict acetabular component loosening and the Gruen method to determine femoral component loosening.

Of the 99 hybrid hips, 57 were right and 42 were left hip arthroplasties and 6 patients had bilateral consecutive hips done. 5 were performed for revision of fractured necks of femur in Birmingham hip resurfacings and one total hip arthroplasty revised to a hybrid and the remaining 92 were primary hybrid hip arthroplasties. The arthroplasties were performed for Osteoarthritis (89), Rheumatoid arthritis (4), and others (6). At mean follow up of 4.2 years, no aseptic loosening was noted radiologically or clinically, no components have been revised for failure or loosening and no components have dislocated.

The use of high dose local infiltration NSAIDs in the intraoperative and early post operative phase does not seem to affect prosthetic fixation at-least during short to mid term follow up of total hip joint arthroplasties.

This bone preserving procedure is less well described in the much older population over 65 years of age. Despite good bone quality, independence and active lifestyle, older age seems to be a deterrent for hip resurfacings among most orthopaedic surgeons.

Analysis of 111 Birmingham hip resurfacings in 105 consecutive patients from 1999 to 2007 performed by a single surgeon was carried out to determine radiological and clinical outcome. The unique selection criteria looked at joint disease, activity levels, general health, imaging (Xray/CT/MRI) and Bone density studies.

28 females and 77 males with mean age of 69.5 years (65–87 years, SD +/− 4), body mass index of 27.2 (19–40.4, SD +/− 3.8) underwent resurfacings. 8 patients had bilateral, consecutive 2 stage procedures. Mean Follow up was 3.8 years ranging from 3 months to 7 years. 62 resurfacings were performed in the age group 65–69 yrs, 32 resurfacings in the 70–74 age group, 12 resurfacings in the 75–79 age group and 4 resurfacings in the 80–89 age group. 77 patients (71.3%) stayed one night or less in hospital. 4 patients (3 males and 1 female) had postoperative fracture neck of femora.

Radiographic review at the most recent follow up revealed non of the patients (101) who had the original hip resurfacing components had any evidence of gross loosening, migration or subsidence requiring revision of either the cup or the femoral components. No patients complained of localised hip pain and at the most recent follow up they had very good to excellent function with no report of dislocations.

Hip resurfacing is a challenge in patients who are over the age of 65 years. Using our selection criteria, it may be offered to active, independent patients with good bone quality as this age group in the population becomes larger with time.

Birmingham Hip resurfacings have been a popular mode of treatment for younger and more active patients with arthritis of the hip. However the use of hybrid hip arthroplasty system with a Birmingham hip resurfacing cup and modular head with a variety of cemented/uncemented stems is less well described in the literature.

We analysed radiographic and clinical outcomes of 99 consecutive hybrid hip arthroplasties performed by a single surgeon between 2000 and 2006.

A total of 93 patients (52 females and 41 males) with an average age of 69.9 (47 to 88) and average BMI of 28.8 (18.7 to 140.9) had arthroplasties with a mean follow up of 4.1 Yrs (1 to 6.3 years). 57 right and 42 left hip arthroplasties were performed of which 6 patients had bilateral consecutive hybrid hip arthroplasties.

93 were performed for osteoarthritis, 4 for RA, 5 patients for revision of failed hip resurfacing arthroplasties with #NOF and 1 revision for failed THR.

No patients had dislocations and one patient had revision of a resurfacing cup secondary to hip pain due to excessive cup anteversion, no loosening of components were identified at the most recent follow-up and all patients were mobilising well with no complaints of pain.

Hip Resurfacing procedures are gaining popularity in the younger individuals with arthrosis of the hip. Some patients who are fairly independent and active fall short of satisfying the criteria for a hip resurfacing and we preferred the option of the Birmingham hip resurfacing cup with a large modular head and a compliment of stems. This metal-on-metal option with large heads would ideally increase stability and reduce wear patterns with the prospect of increasing longevity of total hip arthroplasties.