The Oxford medial unicompartmental knee replacement has been shown to provide good long-tern results in numerous studies with survivorship at 10 years ranging from 82% to 100%. This prospective study describes the survival of 265 Oxford unicompartmental knee replacements implanted in one centre from 1995-2009. 8 were lost to follow up. 40 of the 265 knees were revised. For operation performed from1995-1999 the risk of revision at 5 years was 10%, operations from 2000-2004 the risk of revision was 15% and from 2005-2009 the risk of revision at 5 years was 36%. This study demonstrates that since 2005 there has been a significant increase in early failure of the Oxford unicompartmental knee at this institution and discusses the possible reasons for this

Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific. Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns. In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically. To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2). We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis

Background. A number of studies have reported on the early failure of the Oxford unicompartmental knee arthroplasty. However, less evidence is available regarding the outcome following revision of failed unicompartmental knee prostheses to total knee arthroplasty. The aims of this study were to determine the time to failure for the Oxford unicompartmental knee arthroplasty and to assess the short-term outcome following revision surgery. Methods. Details of consecutive patients undergoing revision of an Oxford unicompartmental knee arthroplasty to a total knee arthroplasty at our centre between January 2000 and December 2009 were collected prospectively. Data was collected on patient demographics, indication for revision surgery, and time to revision from the index procedure. Clinical and radiological outcome following revision arthroplasty was also assessed. Results. During the study period 22 (4.5%) of 494 Oxford unicompartmental knee arthroplasties were revised to a total knee arthroplasty. Mean age at the time of revision surgery was 61.8 yr and 13 (59%) patients were male. Mean time to revision surgery from the primary procedure was 3.0 yr (range 0.6–6.2 yr). The commonest reasons for revision were aseptic loosening of the femoral (n=9) or tibial component (n=2), and undiagnosed (n=5) or patellofemoral pain (n=2). All patients were revised to a cemented total knee arthroplasty with most not requiring bone grafts. During follow-up (range 0.5–4.5 yr) no further surgery was performed in the 22 patients. In addition, there were no major postoperative complications and no evidence of radiological failure. Discussion. The present study demonstrates most failures of the Oxford unicompartmental knee arthroplasty occur within three to four years following the index procedure and are due to aseptic component loosening. These findings are consistent with other published reports regarding the early failure of this particular prosthesis. The short-term outcome following revision surgery appears to be good, however longer follow-up periods are required to determine if these good results continue

Hip resurfacing arthroplasty is an established and effective intervention for osteoarthritis of the hip in the young active patient, relying on the principle of femoral bone-stock preservation. A recognised mode of failure is neck thinning leading to radiological evidence of neck collapse and clinical failure. We report on a series of these slow-neck-failure patients and highlight the increased incidence of this phenomenon in post-menopausal female patients. This is a single operator, single implant series; 172 cases were identified from databases at our institution. 76 were female, mean (SD) age 52 (7) years. 96 were male, mean (SD) age 51(12) years. 15 (8.7%) patients required revision. 12 (80%) were female, 9 (75%) of these were due to slow neck failure. In the men one patient developed ALVAL requiring removal of his bilateral hip resurfacings, the other failure mode was early femoral neck failure. Mean time to failure was 6 months in men and 37 months in women. This difference in failure rates is also seen in the NJR figures. This review confirms the relatively high incidence of premature failure in post-menopausal females. NICE guidance in 2003, currently under review, stated that resurfacing is indicated in male patients up to 65 and female patients up to 60. As a result of this study we are currently advising post-menopausal patients that this risk of early failure may make total hip replacement a preferable option to resurfacing arthroplasty

Component malalignment has long been implicated in poor implant survival in Total Knee Arthroplasty (TKA). Malalignment can occur in orientation of bony cuts, and in component cementation/implantation. Several systems exist to aid bony cut alignment (navigation, shape matching), but final implantation technique is common to all TKA. Correction of errors in bony cut alignment at cementation/implantation by surgeons has been described. Changes in alignment at this stage are likely to result in asymmetrical cement penetration, which is implicated in early failure. This study reviewed a consecutive series of 150 primary cemented TKAs using an imageless navigation system (aiming for neutral overall limb alignment). Deviation at implantation was calculated by comparing limb alignment recorded using the trial components with limb alignment recorded with the final implanted components, prior to closure. 136 patients (91%) had a final overall limb alignment within 2° of neutral. Three patients (2%) had a final overall limb alignment greater than 3° from neutral. Deviation occurring at implantation is shown in Figure 1 with deviations distributed around zero (mode 0, median 0.3, range −2 to +4,)

Distal clavicle fractures have a significant non-union rate, and are often managed operatively. Many of the fixation devices used have a high complication rate or require removal. An arthroscopic technique using the Tightrope device (Arthrex) has been used in our institution. We aimed to describe our initial results. Eighteen cases were identified retrospectively, and the notes and radiographs reviewed. Twelve patients were male, six female, with mean age 33 years. All fractures were displaced, lateral to the coraco-clavicular ligament complex: six showed marked comminution. Mean follow-up was thirteen weeks. Fifteen fractures united, with a mean radiological time to union of 8 weeks (range 6-13 weeks). There were three surgical complications. In one, the clavicular button was not seated correctly on bone, and early failure required revision surgery. In another, there was inadequate reduction, radiographic non-union at five months and subsequent device failure. In the last, there was radiographic non-union, but the patient was asymptomatic. The arthroscopic tightrope device provides minimally invasive stabilisation and reliable union. The complications seen were related to incorrect technique, and anticipate the complication rate to diminish as the technique is developed. We recommend the use of this technique for the stabilisation of distal clavicle fractures

Background. Pseudotumours have been associated with metal-on-metal (MoM) hip replacements. We define it as a solid mass which may have cystic components that is neither neoplastic nor infectious in aetiology. The cause of a pseudotumour is not fully understood but could be due to excessive wear, metal hypersensitivity or due to an as-yet unknown cause. Aim. We present the retrieval analysis of early failure MoM hips revised for pain, loosening or a symptomatic mass. Tissues and implants were examined for the possible causes of failure and pseudotumour formation. Corrosion as a potential new cause for pseudotumour formation will be presented. Methods. A group of 16 MoM hip replacements were collected for retrieval analysis. Six of which had a pseudotumour. An Artificial Hip Profiler (Redlux Ltd) was used to measure wear. Edge loading was determined using the 3D wear data. Tissues were histologically evaluated using a 10-point ALVAL scoring system, which strongly suggests hypersensitivity (1). Cases were assigned to one of three categories: high wear (rates >5m/yr), hypersensitivity or corrosion. Results. Of the 6 pseudotumours, 3 had edge loading, 2 had high ALVAL scores and one had corrosion at the head taper junction. The high wear group, (3 cases) all demonstrated edge loading. Histology revealed more metal wear particles and macrophages, with a low ALVAL score in these cases. Two cases were found to have hypersensitivity with a high ALVAL score, more lymphocytes with less visible wear debris and macrophages. The wear rates were also lower, <4m/yr. One total hip replacement had corrosion at the junction between the head and adaptor taper for the stem. The bearings had low wear and the tissue had extensive necrosis as well as products of corrosion enclosed in fibrin (2). There was no suggestion of hypersensitivity (low ALVAL score). Conclusion. Pseudotumours can be caused by high wear, but if this is ruled out, a hypersensitivity or corrosion product reaction should be considered

Background. Metal on metal hip resurfacing has become popular worldwide for younger patients because of perceived advantages in function and ease of revision, due to bone conservation. Joint Registry data have shown increased risk of early failure, particularly in younger females. There have been few studies comparing the outcome of resurfacing to cemented total hip arthroplasty (THA). Methods. 715 Hip Resurfacings (HR) performed between 2000 and 2010 with up to 10 years follow-up were compared with 2210 Exeter cemented Total Hip Arthroplasties (THA) performed for all diagnoses during the same period within our region. Survivorship was recorded using revision for any cause as the end point. Harris Hip Scores were collected pre-operatively and at 1,3,5 and 7 year review. Prospective independent analysis was carried out using Kaplan Meier survivorship, and non-parametric testing to investigate the effect of age (under 55 and over 55) and gender on revision rate and Harris Hip Score. Results. Over the 10 year period survival of Exeter THA was better than HR overall. Revision rate 2% for THA and 7% for HR; P < 0.0001. There was no significant difference in risk of revision between THA and HR in males at any age. In females there was a significantly increased revision rate with HR. Under 55 Revision rates: THA 0%; HR 6.7%. 55 & over Revision rates: THA 1.3%, HR 5.9%, P < 0.0001. Harris Hip Scores were significantly better overall in the HR group. Sub-group analysis showed that Harris Hip Scores were not significantly different for males under 55. In all other groups (males over 55 and females under and over 55) Harris Hip Scores were better after HR compared with THA. Conclusions. In this series survivorship and functional scores for HR are at least as good as for THA in males. The increased risk of revision after HR in females should be weighed against advantages of bone conservation and better post-op hip scores

Aims

The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years. There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p= 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods

Aims

The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.

Introduction. Femorotibial malalignment exceeding ±3° is a recognised contributor of early mechanical failure after total knee replacement (TKR). The angle between the mechanical and anatomical axes of the femur remains the best guide to restore alignment. We investigated where the femoral head lies relative to the pelvis and how its position varies with respect to recognised demographic and anatomic parameters. We have tested the hypothesis of the senior author that the position of the centre of the femoral head varies very little, and if its location can be identified, it could serve to outline the mechanical axis of the femur without the need for sophisticated imaging. Patients & Methods. The anteroposterior standing, plain pelvic radiographs of 150 patients with unilateral total hip replacements were retrospectively reviewed. All patients had Tönnis grade 0 or 1 arthritis on the non-operated hip joint. All radiographs were obtained according to a standardised protocol. Using the known diameter of the prosthetic head for calibration, the perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured with use of TraumaCad software. Anatomic parameters, including, but not limited to, the diameter of the intact femoral head, were also measured. Demographic data (gender, age, height, weight) were retrieved from our database. Results. There were 72 men and 78 women with a mean age of 67.0 years. The mean distance of the centre of the femoral head to the pubic symphysis was 89.1 mm (standard deviation [SD], 5.8 mm). This distance was higher in men (mean, 90.5 mm; SD, 5.6 mm) than in women (mean, 87.7 mm; SD, 5.8 mm) (p=0.003). No statistically significant correlations between this distance and body-mass index or age (p=0.57 and p=0.28, respectively) were revealed. However, height was strongly correlated with this distance (r=0.52, p < 0.01), as was the diameter of the femoral head (r=0.61, p < 0.01). The latter was significantly larger in men than in women (p < 0.01). Conclusion. This is the first study to demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. As expected, it varies with patient's height and gender. Although statistically significant, the difference between genders is < 3 mm and can be explained by the smaller femoral head size of females. Our findings should prove useful during TKR surgery, as they facilitate intra-operative identification of the centre of the femoral head. Based on these results, simple trigonometry shows that if a surgeon measures 9 cm from the symphysis pubis, a line from this point to the centre of the knee will be within 2° and 2.2° of the true mechanical axis in 98% (i.e. ± 3 SD of the mean) of male and female patients, respectively

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population. This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer.

The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis.

Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score.

Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437).

Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable.

Cite this article: Bone Joint J 2015;97-B:532–8.

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO.

The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome.

Cite this article: Bone Joint J 2013;95-B:95–100.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function.

Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome.

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures.

The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.

We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed.

At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.