Introduction. Despite being from different manufacturers, Exeter stem and Ogee cup are commonly used together as cemented ‘cross breed’ combination in United Kingdom. The purpose of this study was to evaluate the long-term outcome of this combination. Materials and methods. The ten years outcome of 131 primary hip replacements using an Exeter stem and an Ogee cup combination were studied retrospectively from clinical audit data and radiographs. Results. The Harris Hip score (HHS) improved significantly from 46 pre-surgery to 88 post-surgery. This had a gradual decrease to 81 over ten years. This effect was associated with a decrease in function score but a sustained pain score. Radiologically, five cups were loose and two stems had failed. One stem had migrated and another had progressive endosteolysis. There were two recurrent dislocations, of which one was revised to a bipolar socket. The ten year survival of the combination implant was 99% (CI 97 to 100) with revision as an end point. The same with impending failure as end point was 93% (CI 87 to 99). Conclusion. It might be preferable to have a multi-centric prospective study to demonstrate the performance of this commonly done combination implant at various settings. In the meantime it is concluded that the Exeter stem-Ogee cup combination arthroplasty has acceptable outcomes at ten years

Total knee replacement (TKA) surgery is an excellent and well-proven procedure for the treatment of end stage arthritis of the knee. Many refinements have taken place over time in an attempt to improve the components, wear qualities of the polyethylene, and the surgical technique to improve accuracy of component positioning, reduce patient pain, improve postoperative range of motion, ultimately improve results and to prolong the time until revision surgery may occur. This study examines the results of a gap balancing surgical technique in which components were implanted that had a posterior cruciate substituting design. This technique is performed with exacting alignment and balancing of the flexion and extension gaps prior to implantation of the knee components. The follow up is at a minimum of ten years. 515 consecutive knee replacements were followed prospectively for a minimum of ten years. The average age at surgery was 70 years, 73% of patients were female, with an average BMI of 31. All patients carried a diagnosis of osteoarthritis and a cemented, posterior stabilized design TKA (Balanced Knee System, Ortho Development) was implanted. All cases were performed by one of two experienced joint replacement surgeons. The surgical technique demanded flexion and extension gap balancing as well as soft tissue balancing prior to finishing cuts being performed on the femoral side (See figures 1 and 2). Polyethylene spacers come in 1 millimeter increments. 28% of patients died postoperatively at an average of 7.4 years. These patients were older on average at the time of index surgery (76.6 years). None had undergone revision surgery. Of the remaining patients Knee Society scores (39 preop to 91 post op at ten years), function scores and range of motion all improved significantly. What's more, these results were not diminished at ten years. There were no component failures and less than 1% radiographic progressive lucent lines. Eleven revision surgeries (2.1 %) were performed with 2 acute superficial wound revisions, 3 late infections, one patellar tendon disruption from a fall at 7 years (BMI 45.7), 2 complete revisions performed elsewhere for unsatisfactory results, and 3 spacer exchanges for perception of postoperative laxity. For the current study we also examined subgroups of the morbidly obese, octogenarians, and those with a preoperative valgus deformity of greater than 15%. At follow-up these subgroups fared very well with the exception of the heaviest BMI's being limited in range of motion because of soft tissue impingement. Results suggest that this balancing technique gives excellent results with few complications at ten year evaluation. We believe that careful attention to bony and soft tissue balancing and equalization of gaps in flexion and in extension will prove beneficial for TKA longevity in even longer-term evaluation. Figures 1 and 2 demonstrate gap balancing blocks and alignment rods in extension and in flexion

Anterior cruciate ligament (ACL) reconstruction is a commonly performed operation. A variety of graft options are used with the most popular being bone-patellar-tendon-bone and hamstring autograft. There has been an increase in the popularity of hamstring autograft over the past decade. The aim of the study was to assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction. 86 patients underwent anterior cruciate reconstruction by two knee surgeons over a 12 month period (January 1999 to December 1999). 80 patients meet the inclusion criteria of arthroscopic ACL reconstruction. The same surgical technique was used by both surgeons involving four-strand STG autograft, single femoral and tibial tunnels and aperture graft fixation with the Round headed Cannulated Interference (RCI) screw. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up. 80 patients underwent anterior cruciate reconstruction with average age 30.9 years (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire. The median Lysholm Knee Score at ten years was 94 (52 to 100). The median activity level had decreased from 9 to 5 at ten years according to the Tegner Activity Scale. 73% of patients reported a good or excellent outcome on the Lysholm score. The group of patients was further divided into those that required meniscal surgery and those that did not. The patients that did not require meniscal surgery had a median Lysholm score of 94 and those that required meniscal surgery had a similar median Lysholm score of 92.5. However it was noted that 8 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a median Lysholm Knee Score of 83.5 and Tegner Activity Scale of 4 at ten years following reconstruction. 17 of the 62 patients (27.4%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture. In conclusion anterior cruciate ligament reconstruction with four-strand STG hamstring autograft provides a reliable method of restoring knee function, with a 6% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator of function at ten years

BACKGROUND

Despite many years of clinical experience the optimal bearing choice in total hip arthroplasty (THA) remains controversial. This study aims to directly compare the three widely used bearing surfaces: metal-on-highly crosslinked polyethylene (MoHXLPE), ceramic-on-ceramic (CoC) and metal-on-metal (MoM), regarding clinical and radiologic outcome parameters.

Aim

(1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN.

Hypothesis

The Synergy femoral component was introduced in 1996 as a second generation titanium proximally porous-coated tapered stem with dual offsets to help better restore femoral offset at THR. The purpose of this prospective study was to evaluate the long-term (minimum 10 year) clinical and radiographic results and survivorship of this femoral component at our institution.

Background

Surgeons always must take into account that a primary total hip arthroplasty (THA) in a young patient will be revised in the future, this because of the long life expectancy of young THA patients and the limited durability of prosthetic implants in these patients. Therefore we would like to accentuate the revisability of a primary THA in this specific and high demanding patient population.

Introduction

The success of total hip arthroplasty has meant its indications have been extended to the younger more active patient. Due to the higher activity levels and increased demands of these patients, revision rates have been traditionally higher than when compared to older patients [1]. Ceramic on ceramic bearings may offer a viable long term solution as manufacturing methods have evolved resulting in improved mechanical properties, particularly of third and fourth generation ceramics. We report the outcome of primary cementless, alumina-on-alumina hip arthroplasty with a minimum 10 year follow up in 110 patients under the age of 55 years of age at time of surgery.

Background

Autologous chondrocyte implantation (ACI) and mosaicplasty (MP) are two methods of repair of symptomatic articular cartilage defects in the adult knee. This study represents the only long-term comparative clinical trial of the two methods.

Aim. This study quantified changes in the microbiology of osteomyelitis in a single specialist centre within the UK. The rate of infection with multi-drug-resistant (MDR) bacteria was measured over a ten year period in 388 patients. Method. Patients with confirmed osteomyelitis who received curative surgery from 2013–2017 were included (n=222). Microbiology was compared to patients from a cohort between 2001–2004, using the same diagnostic criteria (n=166). 1. The proportion of MDR bacterial pathogens. 2. from deep tissue culture in these cohorts were compared. Pathogens were analysed according to aetiology and the presence of metal-work. Results. Both cohorts had similar baseline characteristics. A median of five tissue samples were submitted for each patient. The proportions of specific pathogens remained unchanged between the two cohorts, with the exception of a decrease in the proportion of coagulase-negative Staphylococcus (CoNS) (12.7% vs 5.3%, p<0.05). Although the overall proportion of Staphylococcus aureus remained similar, the rate of MRSA infection decreased in the 2013–2017 cohort when compared to the 2001–2004 cohort (30.7% vs. 10.5% of Staphylococcus aureus, p<0.05). However, the proportion of MDR Enterococcus, Pseudomonas and Enterobacteriaceae did not differ between the two cohorts (37.3% vs. 35.7%). There were no differences in microbiology of the 2013–2017 cohort that related to presence of metal-work or aetiology of infection. A higher proportion of haematogenous osteomyelitis were culture-negative compared to other aetiologies (37.1% versus 20.3%). Conclusions. In this UK centre over the past 10 years, rates of MRSA osteomyelitis have fallen by two thirds, which is in line with the reducing rate of MRSA bacteraemia nationally. However, the proportion of other MDR bacteria remained unchanged. A decrease in the proportion of CoNS may reflect improved sampling technique and culture. Furthermore, this study demonstrated that classification by aetiology or the presence of metal-work does not predict the pathogen in adults with chronic osteomyelitis

Unicompartmental knee arthroplasty (UKA) has a long history that extends back nearly as far as the first tricompartmental designs. While initial results were erratic, with a greater understanding of patient selection and surgical techniques, more consistent and favorable results have been reported. While there has been somewhat of a resurgence in interest in UKA, the percentage of primary knee arthroplasties that are unicompartmental hovers around 6–8%. It is my belief that you should be doing more!. Several peer review studies suggest that with both fixed and mobile bearing designs, survivorship exceeds 90% at ten year. In our own initial series of 62 fixed bearing medial UKA, survivorship was 90% at 20 years. UKA is an outstanding option for younger patients, who are amongst the most challenging to satisfy with a TKA. In a cohort of patients < 55 years old, Biswas et al. reported a mean KSS of just over 95 points and a mean UCLA activity score of 7.5. This is opposed to the report by Parvizi et al. who suggested 1/3 of young, active patients reported residual symptoms and limitations following modern TKA. Most data suggests that UKA is a less morbid procedure than TKA. In a retrospective review of 605 UKA compared to 2235 TKA, Brown et al. found the risk of complications was 11% vs. 4.3% favoring UKA with a shorter length of stay and risk of discharge to an extended care facility, which also translates into lower costs for our health care system. Finally, in the only randomised study that I am aware of that has compared UKA and TKA, UKA was associated with significantly better survivorship (90% vs. 79%). Further, UKA was associated with better ROM and functional scores at 5 and 15 years. Finally, recovery with UKA was faster and the risk of peri-operative complications was lower

Adequate fixation of implant components is an important goal for all arthroplasty procedures. Aseptic loosening is one of the leading causes of revision surgery in total knee arthroplasty. Radiostereometric analysis (RSA) is an imaging technique to measure implant migration, with established migration thresholds for well-fixed, at risk, and unacceptably migrating components. The purpose of the present study was to examine the long-term fixation of a cemented titanium fixed bearing polished tibial baseplate. Patients enrolled in a previous two-year prospective trial were recalled at ten years. All patients received a cemented, posterior-stabilised total knee replacement of the same design implanted by one of three surgeons. Of the original 35 patients, 16 were available for long-term follow-up, with one patient lost to follow-up, nine patients deceased, and a further nine patients unwilling to return to the clinic. Each patient underwent RSA imaging in a supine position using a conventional RSA protocol. Migration of the tibial component in all planes as well as maximum total point motion (MTPM) was compared between all time points (baseline, six weeks, three months, six months, one year, two years) up to the ten year follow-up visits. Outcome scores including the Knee Society Score (KSS), WOMAC, SF-12, and UCLA Activity Score were recorded. At ten years, the mean migrations of the tibial component were less than 0.1 mm and 0.1 degree in all planes relative to the post-operative RSA exam. There was no significant difference in tibial component migration between time points. However, MTPM increased significantly over time (p = 0.002), from 0.23 ± 0.18 mm at six weeks to 0.42 ± 0.20 mm at ten years. At one year, 13 patients had an acceptable MTPM level, three patients had an ‘at risk’ level, and no patient had an ‘unacceptable’ level. No patients were revised at ten years. WOMAC and KSS were significantly improved (p < 0.0001) at the latest follow-up compared to pre-operatively, but there was no difference in SF-12. The median UCLA Activity Score at latest follow-up was six (range, two to eight). The tibial baseplate demonstrated solid fixation at ten years. No patients had an unacceptable MTPM level at one year and no patients were revised at ten years, supporting the use of RSA to predict long-term loosening risk. The low level of tibial baseplate migration found in the present study correlates to the low rate of revision for this implant as reported in individual studies and in joint replacement registries

BACKGROUND. Patella resurfacing in TKA remains controversial. The purpose of this study was to compare the long-term clinical outcome in TKA in patients undergoing bilateral TKAs with one patella resurfaced and the other patella nonresurfaced. METHODS. Twenty-nine patients (58 knees) underwent primary bilateral TKA for osteoarthritis. These patients were enrolled in a prospective randomised double blinded study and represent a subset of a larger study of patella resurfacing. All patients received the same posterior cruciate sparing TKA. Patients each had one knee randomised to treatment with or without patella resurfacing. The contralateral knee then received the alternative patellar treatment, such that all patients had one knee with a resurfaced patella and the other nonresurfaced. Clinical evaluations consisted of routine radiographic and clinical follow-up and included with a Knee Society Score patellofemoral specific patient questionnaire. Twenty-eight patients (56 knees) participated and were followed for a mean of 118 months (range, 69–146 months). RESULTS. There were no significant differences between the knees treated with and without patellar resurfacing with regard to range of motion, KSCRS, or the pain and function scores. Forty-six percent (13/28 patients) of patients preferred the resurfaced knee, 36% (10/28) the nonresurfaced knee, and 18% (5/28) had no preference. Two patients (7%) in the nonresurfaced group required revision for a patellofemoral related complication, compared to one patient (3.5%) in the group with a resurfaced patella. CONCLUSIONS. Ten year follow-up reveals equivalent results for resurfaced and nonresurfaced patellae in TKA with regards to ROM, KSCRS, pain and function, or patellofemoral symptoms. In this large series of bilateral TKAs, 64% of patients either preferred the unresurfaced knee or had no preference

The Birmingham hip resurfacing (Smith & Nephew, Tennessee) (BHR) has been used in younger more active patients. Aim. We report on our experience of 206 BHR procedures in patients aged 50 years or less with a minimum ten year follow-up. Clinical outcome scores, body mass index (BMI), gender and age were analysed to investigate resurfacing outcomes. Methods. 200 patients (158 males and 42 females) with an average operation age of 43.33 years (SD ±5.66) were investigated. There were 6 bilateral procedures The mean follow-up period was 12.44 years (SD ±1.71). The arthroplasties were completed between April 1999 and December 2002 by one surgeon. 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. Results. In 1 patient the implant was in situ at the time of death. Revision was carried out in 5 hips (2.4%) at a mean time period of 3.2 years (0–8) post-operatively. Failure was due to femoral neck fracture, acetabular loosening and avascular necrosis of the femoral head, leading to loosening. Kaplan-Meier analysis showed survivorship of 97.6%. The mean Harris Hip scores (paired t-test, p<0.05) improved significantly from 55.58 preoperatively to 91.33 at 15 years. The mean SF-36v2 physical scores (paired t-test, p<0.05) improved significantly from 32.70 preoperatively to 43.75 at 15 years. WOMAC total scores (paired t-test, p<0.05) improved significantly from 44.37 preoperatively to 14.67 at 15 years. Conclusion. In this demanding group of patients, without any restrictions to physical activity, the results of this procedure at 10 years are most encouraging. However, concerns remain in relation to the effect of elevated metal ions, tissue sensitivities, and anatomical variations, such as hip dysplasia, which may impact on function and success

Introduction. Impaction bone grafting for reconstitution of acetabular bone stock in revision hip surgery has been used for nearly 30 years. We report results in a group of patients upon whom data has been collected prospectively with a minimum ten year follow-up. Material and Methods. Acetabular impaction grafting was performed in 305 hips in 293 patients revised for aseptic loosening between 1995 and 2001. In this series 33% of cases required stainless steel meshes to reconstruct medial wall or rim defects prior to graft impaction. These meshes were the the only implants used for this purpose in this series. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of 10 years following the index operation; mean follow-up was 12.4 years (SD 1.5; range 10.0–16.0). Results. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 86% (95% CI 81.1 to 90.9%). Clinical scores for pain relief and function remained satisfactory (mean OHS 33.3, Harris hip score for pain 36.7, Harris hip score for function 27.3). Of the 125 hips still available with at least 10 years of radiographic follow-up, 97 appeared stable and 28 were judged to be radiologically loose; however, there was no significant difference in the pain and function scores between the two groups. The overall complication rate was 11.5%, including 1% peri-operative death, 3.3% dislocation and 0.3% deep infection. Discussion. This is the largest series of medium- to long-term results of acetabular impaction bone grafting with a cemented cup for revision hip arthroplasty reported to date. The technique is particularly successful when used for Paprosky grade 1 and 2 deficiencies; grade 3 deficiencies may be better managed with a different method for reconstructing larger defects e.g. trabecular metal augments. Conclusion. This series shows good long-term results for impaction bone grafting of acetabular deficiencies in revision hip surgery, with survivorship of 86% for aseptic loosening at 13.5 years and satisfactory clinical outcomes

Background. Joint replacement surgery has been shown to be successful in post solid organ transplantation patients. However, complication rates, revision rates, and overall mortality can be higher in this population compared to patients who have not undergone solid organ transplantation. Many transplant patients have a decreased life expectancy. Therefore, literature suggests that joint replacement surgery be offered to qualifying patients early on when symptomatic. This study compares the outcomes of patients who have undergone solid organ transplantation as well as a joint replacement to patients that have only undergone joint replacement surgery. Methods. We retrospectively gathered 42 transplant (T) patients over a ten year period, 2003–2013, that underwent a liver (21) or kidney (21) transplant as well as primary total knee arthroplasty (TKA) (23) or total hip arthroplasty (THA) (19). We then gathered 42 non-transplant (NT) patients matched for procedure, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and age adjusted Charlson co-morbidity index (ACCI) score who only underwent TKA or THA with no transplant. We used Chi-Square, T test, and multivariate analysis to compare the two groups with regard to number of complications (NOC), readmissions at 30 and 90 days post surgery, length of stay (LOS), number of intensive care unit (ICU) admissions, and total direct cost (TDC) per hospital stay. Results. We found no significant difference between the two groups with regard to LOS (P=0.267), readmissions at 30 days (P=0.843) or 90 days (P=0.265), ICU admissions (P=0.326), or TDC per hospital stay (P=0.343). The T group had significantly higher NOC compared to the NT group (P=0.022). The type of transplant was associated with a higher NOC with kidney transplant patients having 6.75 (95% CI 1.318–34.565) times higher odds of complications compared to liver transplant patients (P=0.022). The average time between transplant surgery and joint replacement surgery was 2.9 years. Conclusion. Solid organ transplant patients are considered to be at higher risk for opportunistic infections compared to the general population. Limited data is available regarding the time at which transplant patients are at the highest risk for infection, or if one type of transplant is more at risk for complications than another after THA or TKA. This study suggests that transplant patients undergoing joint replacement surgery at an average of 2.9 years post-transplant are at higher risk for complications than a matched cohort of patients undergoing joint replacement alone, with kidney transplant patients being more at risk to experience a complication than liver transplant patients. To our knowledge, this is the first study to acknowledge the higher risk associated specifically with kidney transplant patients

Purpose of the study:. Recent literature raised concern on the adverse effects, incidence of pseudo tumours and raised blood and urine Chromium and Cobalt levels in patients with a metal on metal articulation. The purpose of this study was to follow up a cohort of patients that received a metal on metal total hip replacement with minimum follow up of ten years and to compare the results with the literature. Methods:. All the available patients that underwent metal on metal total hip replacements during 1999 to 2000 with a minimum follow up of 10 years were clinically examined and evaluated with the Harris Hip Score; X-rays; Full Blood Count; CRP; LFT; U, K & E; blood and urine Chromium and Cobalt levels and Ultrasonic examination of the hip. The ultrasound was done by an independent experienced ultrasonographist in each case to exclude pseudo tumours or fluid collections. The patients were clinically examined to try and find any adverse effects of the metal on metal articulation. Results:. We found one patient that had a revision of the femoral component for a peri-prosthetic fracture retaining the metal on metal articulation that subsequently developed loosening and a pseudo tumour. The remaining patients had excellent Harris Hip Scores and their implants showed no osteolysis or radiological signs of loosening. Conclusion:. Despite the recent concern we obtained good results after ten year follow up with metal on metal prosthesis. However we do recommend careful selection of patients, detailed attention to surgical technique and close follow up when considering metal on metal articulation. Patients should be counselled about the possibility of tissue reaction to the bearing surface and possible future revision surgery

Objective. Retrospective study to assess the outcomes of ulnar shortening for TFCC tear and distal radial malunion. Method. Retrospective note and x-ray review of all patients undergoing ulnar shortening over a ten year period along with a clinic assessment and scoring to date. The ulnar shortening was performed using the Stanley Jigs (Osteotec). A 5–6 holed DCP was used to stabilize the osteotomy site. Physiotherapy was commenced immediately following the surgery to promote prono-supination and wrist exercises. Result. 28 patients studied with one subsequent death. 13 patients with an average age of 53 years underwent ulnar shortening for distal radius malunion, whereas 15 pateints with an average age of 47 years had a primary indication of ulnar abutment with TFCC tear. Six patients underwent reoperation for non-union. 2 patients needed plate removal for prominent metalware. Patients undergoing the procedure for TFCC deficiency compared to radial malunion did worse, on functional scoring (DASH & SF36). Failure to place an interfragmentary screw was associated with a higher risk of non-union. Conclusion. Ulnar shortening is not a benign procedure, especially for the treatment of TFCC insufficiency. Interfragmentary screw placement is important in avoiding non-union

Aims. Several national studies have shown that the rates of joint replacement are rising and this increase may be greater than that expected by population ageing. The aim of this study was to assess local rates of joint replacement at a district general hospital (DGH) and to investigate whether there had been a change in pre-operative functional status of patients over the study period to account for any change in rates of arthroplasty. Methods. This was a DGH based local joint registry programme with independent functional assessment and follow up. All patients undergoing primary total hip replacement (THR) and total knee replacement(TKR) between 1 January 2000 and 31 December 2009 were eligible. Only after being listed for surgery were patients assessed with WOMAC and Oxford Hip or Oxford Knee scores. Catchment population data was obtained from the Office of National Statistics. Results. 5373 joint replacements were performed over the ten year period, 89% had preoperative scoring available. There was an 80% increase in numbers of THR performed and 95% increase in number of TKR performed between 2000 and 2009. This was a significant increase when compared to the local population aged between 60 and 80 years, the size of which increased just 28% over the same period. The average age of the patients remained static over the study period and there was no clinically significant change in any of the pre-operative functional scores. Conclusions. Whilst the incidence of joint replacement increased over the study period, this was not associated with a change in patients' ages or preoperative functional status. Our results suggest that the increases seen are not due to a change in functional threshold for surgery. This is of particular relevance during this time of austerity when funding for orthopaedic surgery may be threatened

Introduction. Modern metal-on-metal bearing resurfacings have been in use for nearly two decades. Local and systemic metal ion exposure continues to cause concern. We could not find a prospective metal ion study in such patients with a 10-year follow-up. This is the first ten year prospective study of metal ion levels in blood and their release in urine following hybrid fixed metal-on-metal surface arthroplasty. Methods. Twenty six patients were included in an ongoing longitudinal metal ion study of patients with unilateral metal-on-metal hip resurfacings. Three of them were excluded due to subsequent contralateral resurfacing and one has relocated abroad. Cobalt and chromium levels were assessed in 12 hour urine collections before and periodically after operation (5 days to 10 years) using high resolution plasma mass spectrometry. Mean age at operation was 53 years and mean BMI 27.9. Results. Hip function questionnaires at the 10-year review showed that the patients have well-functioning pain-free resurfacings (mean Oxford hip score 14.3). Metal ion results show median cobalt and chromium release at 10 years were 8.3 μg/24 hr and 4.35 μg/24 hr respectively. A statistically significant early peak 6 months to 1 year after operation is followed by a steady decrease over the following seven years although the reductions are not statistically significant. Discussion and Conclusion. Elevated systemic metal ion exposure continues to cause concern in patients treated with metal-metal arthroplasties. Our results show that metal release in these bearings shows a reducing trend after an initial peak. The unknown significance of persistent metal ion elevation underlines the need for continued long-term monitoring