Introduction. After total hip arthroplasty, dislocation is one of the most frequent serious early complications. This occurs in part due to impingement (catching and leverage of the neck-cup on the inlay/cup border). Impingement may also negatively impact long-term outcomes. Materials and Methods. A preliminary model for an optimised hip endoprosthesis system was developed to offer a mechanical solution to avoid impingement and dislocation. A computer-supported range of motion simulation using parameters of cup anteversion and inclination as well as torsion and CCD shaft angle was then performed to localise areas of anterior and posterior impingement of typical acetabular cups. Results. Through isolation of the two main trajectories of motion, and modifications with corresponding gaps to the inlay/cup areas as well as oppositional banking in the abduction/adduction plane, the combination of a snap-fit acetabular cup with reduced cup profile was the result: the “bidirectional total hip prosthesis.”. Under standardised parameters, the ranges of impingement for typical implants are not directly opposite one another (at 180°), but are found instead at an angle of 108.3°. Conclusion. Complications such as dislocation and impingement may possibly be avoided with the bidirectional total hip prosthesis. Typical implantation parameters yield an implant design with rotational asymmetry. [Fig. 1, 2]

Aims: The authors report oncological and functional results after 15 acetabular reconstructions, followed tumor resection, with an original technique using homo-lateral proximal femoral autograft and total hip prosthesis. Material and method: The modiþed Musculoskeletal Tumor Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS) were used for functional analysis. Functional results were available for only 10 patients who presented with a minimal of 2 years follow-up. Results: Fifteen consecutive patients, 9 men and 6 women with a median age of 50 years, were managed in our department for acetabular bone malignant tumor. The tumors involved the zones II in 5 patients, the zones II and III in 5 patients. The tumors included 10 chon-drosarcomas, 1 malignant þbrous histiocytoma, 1 radio-induced sarcoma, 1 myeloma and 2 metastasis. The mean follow-up was 31 months (Range, 12 to 50 months). Local recurrence occurred in 1 case and metastases in 3 cases. Three patients died of tumoral disease and one of intercurrent disease. Eight complications were observed: aseptic failure (n=1), obturator nerve damage (n=1), deep infection (n=4), skin necrosis (n=2), pros-thesis dislocations (n=1) and deep venous thrombosis (n=1). Five revision were performed. The mean MTS was 72% (range, 40 to 96%) and the mean TESS was 82.5% (range, 56 to 86%). Fusion occurred in all reconstructions and all patients recovered an active hip abduction and ßexion. Discussion: This original technique, using an autograft and a standard total hip prosthesis, is available for zone II and III acetabular reconstructions

Because we encountered a high failure rate of the acetabular component of the uncemented, hydroxy-apatite coated, Omnifit total hip prosthesis (Osteonics corporation, Allendale, NJ, USA), we conducted a retrospective study of 418 consecutive total hip arthroplasties with a mean follow up of 60 months. The results of 418 hydroxy-apatite coated, uncemented Omnifit total hip arthroplasties, conducted between 1989 and 1996 were evaluated. Two different acetabulum cups were used: 145 screwcups with one central screwhole, and 273 press fit (PF) cups with several screwholes. The internal geometry of these cups and the fixation of the polyethylene insert in the metal cups were identical. In 339 arthroplasties a 32-mm femur-head was used, in 79 a 28-mm head. Patients’ records and x-rays were evaluated for clinical findings, polyethylene (PE) wear, acetabular and femoral osteolysis and findings during revision surgery. Revision surgery was performed in 73 patients, mainly because of symptomatic acetabular osteolysis (79%). Mean PE wear was 0.16 mm/year (0.19 mm in PF cups, 0.11 mm in screwcups). Acetabular osteolysis was found to be present in178 hips (70 screwcups and 108 PF cups). In both cupdesigns the osteolysis was mainly found around the screwholes of the metal cups. During revision surgery these osteolytic defects were a lot larger than suggested by x-ray imaging. In 22.6% of the hips osteolysis was also present in the proximal femur. Kaplan-Meier survival analysis showed, after 6 year follow up, a better survival for of the screwcup (96%, confidence interval 93–99%) than the PF cup (66%, 95%CI 56–77%). We hypothesized that this specific combination of metal cup and polyethylene insert -possibly due to an insufficient fitting- is responsible for the migration of polythylene wear particles through the screwholes in the metal cup, causing acetabular osteolysis and neces-satating revision surgery. For this reason we abandonned the use of this type of uncemented acetabular component

The ABG total hip prosthesis had been studied to prevent any kind of stress shielding and to allow the localization of the loads in the metaphiseal region of the femur. The aim of this study was to analize the effective behaviour of the loads in long-term implants and the possible correlations of those findings with the clinical situation of the patients. We considered 87 total hip arthroplasty implants executed from 1989 to 1995 and performed by using Anatomique Benoist Girard I uncemented prosthesis. The radiographical findings have been classified observing Engh’s stability criteria according to Gruen’s subdivision of the periprosthetic femoral zones. The radiographical analysis shows a higher presence of can cellous densification in Gruen’s zones 3 and 5 than the one found in zones 2 and 6. Furthermore the presence of a cortical reaction is more relevant in the distal zones.> Radiolucent lines are present in 16% of the cases in zone 4; their percentage in zones 3 and 5 decreases to 7.14% and 10.71%. Our study shows the certain presence of the stress shielding mechanism in long-term analysis and documents that the main region of late anchorage is the distal, not hydroxyapatite-coated, one.> The comparison with other similar studies shows the decrease of the presence of radiolucent lines in proximal femoral zones with the rise of the follow-up: it can be interpreted as the lesser presence of micro movements of the tip of the prosthesis due to the distalization of the anchorage

Purpose: The surgical approach is an essential element for precise reduction and rigid fixation of fractures of the acetabulum. In cases where the anterior column is mainly involved and total hip arthroplasty (THA) is indicated, classical approaches do not allow double assess to the anterior column necessary for reduction and fixation and to the femoral canal for insertion of the prosthesis. Combining Heuter’s anterior approach and Letournel’s ilio-femoral approach provides access to the anterior column and to the often associated posterior hemi-transverse fracture, while allowing insertion of the total hip prosthesis. Material and method: This combined approach was used for ten among 60 THA performed for fracture of the acetabulum. Seven were primary procedures and three were differed reconstruction procedures. Mean patient age was 60.6 years (range 50 – 85 years). Fracture types were: acetabular wall and anterior column (n=8), anterior column and posterior hemi-transverse (n=2). All fresh fractures exhibited major acetabular damage associated with fracture of the femoral neck. A hybrid THA was used for all cases after fixation of the fracture. The femoral heads were used as graft material for deficient anterior columns in two patients and as “piecemeal” grafts for the others. Results: Mean follow-up was 36 months (range 24–35 months). At last follow-up all fractures had healed and all acetabular components exhibited solid fixation with no sign of migration. The mean outer diameter of the ace-tabular components inserted was 56 mm (52–64) using a 2 mm press-fit and one screw. The only complication was one postoperative anterior dislocation. Pain relief and function were satisfactory in all patients at last follow-up with a Postel Merle d’Aubigné score of 16 (13–18). Discussion: This anterior surgical approach enables good access to the acetabular walls and anterior columns, allowing solid fixation and relatively easy THA. The Kocher-Langenbech approach is still better in case of posterior deficiency or when posterior fixation requires space for inserting an acetabular component. We reserve it for THA used to treat fresh fractures of the acetabulum with major damage to the acetabulum and/or the femoral head, with or without neck fracture in patients aged 55 years or more. For differed reconstruction, we also use this approach if the acetabular damage involves the anterior column

Introduction. Total hip arthroplasty in young patients is still associated with high failure rates, especially at the acetabular side. Purpose of this study was to evaluate the long-term results of the Alloclassic cementless Zweymüller total hip prosthesis in patients younger than 50 years at the time of surgery. Methods. Between 1987 and 1994, 73 Zweymüller total hip arthroplasties with a titanium threaded cup were placed in 67 patients younger than 50 years. Mean age at surgery was 43 years (23–49 years). Patients were followed clinically with use of the HHS, revisions were determined and radiographs were analyzed. Kaplan-meier analysis was used to determine survival for different endpoints. Results. Three hips were revised for septic loosening, 3 cups for aseptic loosening and 1 hip because of periprosthetic fracture. Four patients (4 hips) died and 8 patients (9 hips) were lost to follow-up without any revision. 48 patients with 53 prostheses could be evaluated after a mean follow-up of 208 (170–253) months and the mean HHS was 90 (52–100). Cumulative survival analysis with endpoint revision for any reason was 89% (C.I. 85–93) at 17 years. With endpoint aseptic loosening, survival was 95% (C.I. 91–98) at 17 years. Conclusion. Alloclassic Zweymüller total hip arthroplasty with a titanium threaded cup showed good long-term results, even in this group of patients younger than 50 years

Purpose: Wear of prosthetic implants, especially the metal-polyethylene head-cup couple, and dissemination of wear particles throughout the organisms the dominant long-term complication of total hip arthroplasty. We determined serum concentrations of chromium, cobalt, nickel, and molybdenum in patients bearing a total hip prosthesis with a chromium-cobalt metal-poly-ethylene head-cup couple. The purpose of our work was first to compare the levels observed with those found in a control population and then to study variations in these levels as a function of clinical and radiological signs commonly searched for during the follow-up of patients with a total hip arthroplasty. Material and methods: During a period of 30 months, a total hip arthroplasty (PVL®) was implanted in 53 patients suffering from degenerative hip disease. Forty-eight patients were assessed at a minimum follow-up of 32 months with physical examination and standard x-rays as well as serum assay of the specified metals using mass spectrometry on whole blood samples. The control group was composed of 56 patients scheduled for total hip arthroplasty. Results: At a mean follow-up of 44 months, 17% of the patients had a fair or poor functional score and 37% had radiological signs suggestive of femoral stem loosening. There was a significant increase in the serum level of cobalt compared with the control group. This increase was greater in patients with radiological signs of loosening. Discussion: The metal-on-metal couple does not appear to be the only couple which increases serum metal levels. Serum metal assay could be a diagnostic tool useful for following patients with total hip prostheses

Introduction: “Spongiosa metal” this unique implant surface was introduced in 1982 by ESKA implants Germany. Pore size was between 800 and 1500 microns with an overall porosity of 60%. The pore depth of the interconnecting surface structure reached up to 3000 microns. The purpose of this retrospective study is to report the long term results of Spongiosa Metal I cement less total hip prosthesis in Japan. Materials and Methods: Between 1986 and end 1990 total 113 prostheses were implanted and consecutive 106 implants could be evaluated. The all evaluated prosthesis combined 28mm ceramic head and polyethylene inlay. Results: Average follow up period was 17 years. 2 cups and 1 stem were revised by aseptic loosening. 2 stem breakage and 7 ceramic head fracture were seen while following up. 85% of the patients had retained the original prostheses (cup, stem, ceramic head, and inlay). Survival rate was investigated by Kaplan-Meier method. Survival rate for the cup component was 95%, and for the stem component was 93%. Discussion: Main reason of the revision surgery was the ceramic head fracture (7 implants 6%). We thought that beating with the hammer when we install the ceramic head to the taper was one problem. On the other hand, few aseptic loosening was seen while following up. These results suggest that spongiosa metal system can bear for long term of use. Conclusion: 85% of the patients had retained the original prostheses average 17years following up period. Main reason for the revision surgery is ceramic head fracture. We are convinced with this spongiosa metal surface can bear long term of use

Purpose: A spacer can be used for two-phase replacement of an infected total hip prosthesis. The goal is to facilitate reimplantation by avoiding soft tissue retraction. Several types of spacers can be used. We searched for a spacer which avoids wear debris due to methacrylate friction against bone, delivers a local antibiotic, is easily removed, and does not worsen bone damage. Since 1995, we have used a Charnley Kerboull type prosthesis as a spacer. The purpose of the present study was to 1) verify the absence of spacer-related complications, 2) assess outcome in terms of cure of infection and improved function. Material and methods: We used 14 articulated spacers for two-phasee prosthesis replacement in nine men and five women, mean age 64 years. Erythrocyte sedimentation rate was 32 and C-reactive protein was 17. The mean Postel-Merle d’Aubigné (PMA) score was 3+5+2. All patients were reviewed at a minimum 37 months follow-up. Technique: The approach was generally a digastric trochanterotomy, associated with a more or less extensive femoral procedure (depending on the length of the plug to remove) to achieve removal of all implants and cement. A small-size polyethylene cup was inserted with cement delivering at least one antibiotic on a Surgicel bed to facilitate later extraction. A long small-diameter femoral stem was then inserted (bridging the femoral window) and blocked with cement, also on a Surgicel bed. Partial then total weight bearing was authorised between the phases. Results: There were no dislocations. All patients achieved total weight bearing between the two phases. The same germ identified at the first operation was also identified at the second in two patients, requiring prolonged antibiotic therapy. There was one septic failure, in a different patient. The mean PMA score was 5.7+5.8+5.2. Conclusion: This technique avoids methacrylate wear induced by classical spacers and does not modify polymorphonuclear chemotactism, facilitating the efficacy of medical treatment. Patient comfort is also improved between the two phases and muscle atrophy, which could compromise long-term function, is avoided

Introduction: Unique spongiosa like surface structure was introduced in 1982 by ESKA implants Germany. It is called “Spongiosa-Metal I surface” The purpose of this retrospective study is to report and compare long term results of Spongiosa Metal I total hip prosthesis in Japan and Germany. Method: In Japan, between June 1986 and August 1990 total 113 prostheses were implanted and consecutive 106 implants could be evaluated. In Germany, between May 1983 and December 1985 total 209 prostheses were implanted and consecutive 165 implants could be evaluated. The all evaluated prosthesis combined ceramic head and polyethylene inlay. Results: In Japan, average follow up period was 17 years. 85% of the patients had retained the original prostheses (cup, stem, ceramic head, and inlay). Survival rate was investigated by Kaplan-Meier method. Survival rate for the cup component was 95%, and for the stem component was 93%. In Germany, average follow up period was 21.8 years. 88.5% of the patients had retained the original prosthesis. Survival rate for the cup component was 95%, and for the stem component was 85%. Discussion: Main reason of the revision surgery was the ceramic head fracture (7 implants 6%) in Japan and the stem component loosening (14 implants 8%) in Germany. There was no ceramic head fracture in Germany. We thought that beating with the hammer when we install the ceramic head to the taper was one problem. Stem loosening was seen in undersized stem component. On the other hand, survival rate for the cup component was 95% in Japan and Germany. This was good result in comparison with other reports about long term survival. Conclusion 85% of the patients had retained the original prostheses average 17years in Japan and 88.5% average 21.8 years in Germany. Main reason for the revision surgery is stem loosening and ceramic head fracture. Survival rate for the cup component was 95% in Japan and Germany. We are convinced with this spongiosa metal surface can bear long term use

INTRODUCTION. Cementless Total Hip Replacement surgery is a well established procedure for relative young patients with severe hip disease. Excellent long term clinical results have been published on the performance of the femoral component. With growing clinical experience, our concern focused on excessive wear of the Ultra High Molecular Weight Polyethylene (UHMWPE) ringloc liner of the Mallory Head cementless Total Hip Prosthesis. After its introduction in our clinic in 1997, this implant is still in use without any modification. We were concerned that due to premature liner wear, the performance of this implant would not be compliant with the international guideline on implant survival (NICE guidelines: at 10 year follow up, 90% of all implants should still be in situ). Our objective was to establish the amount of liner wear in our first 200 MH implants. METHODS. Our first 200 patients consecutively treated with Mallory Head prostheses were followed up to obtain a recent digital image. Follow up was complete for 181 (90.5%) of our 200 patients. Ten had died and nine were not able or willing to come for follow up. The mean duration of follow up was 8.3 years (range: 8–13). The 181 recent digital images were classified as either excessive wear or no excessive wear by two independent orthopedic surgeons. Next, liner wear was measured in the 2D frontal plane using PolyWare Pro/3D Digital Version Rev 5.1 software (Draftware Developers, Conway, USA). A threshold for excessive liner wear was set at 0.2mm/year, according to literature. RESULTS. Using software for measuring PE wear, 46.7% of all patients had excessive UHMWPE wear (> 0.2mm/yr). There was no relation between the amount of wear and BMI, gender, component size or the acetabular inclination angle. Thirteen patients (6.5%) were revised. Nine of these revisions were for excessive liner wear or aseptic loosening (4.5%). For now, our series of cementless Mallory Head prostheses is compliant with the NICE guideline on implant survival. However, with the measured amount of wear we expect to see a significant increase in the number of revisions for liner wear in the near future. DISCUSSION. Our clinical observation of premature UHMWPE wear proved correct. The measured amount of UHMWPE wear is consistent with the few other studies published on this subject. Although we present a retrospective study, limiting the strength of our results, we have included a large group of patients with acceptable loss to follow up. It is unclear if the observed wear will lead to a sharp increase in the number of revisions within the next few years. Possibly, future revisions will be complicated by loss of acetabular bone stock following the pathofysiological reaction to wear particles. Our results can probably be generalised for any district hospital

SL-PLUS MIA stem (Smith & Nephew Orthopaedics AG) is a modified implant of Zweymuller type SL-PLUS standard stem (Smith & Nephew Orthopaedics AG). We constructed finite element (FE) models and analysed equivalent stresses in the femur. In addition, we measured bone mineral density (BMD) in the femur by dual-energy X-ray absorptiometry (DEXA) after THA. The purpose of this study was to investigate the equivalent stress and to compare the results of the FE analyses with changes in BMD after THA. Twenty-one patients (18 women and 3 men) who underwent primary cementless THA with SL-PLUS MIA or SL-PLUS formed the basis of this study. Eleven patients received SL-PLUS MIA and ten patients received SL-PLUS. Zones were defined according to Gruen's system (zones 1∼7). Computed-tomography (CT) images of the femur were taken before and at 1 week after THA. FE models of the femur and prosthesis were obtained from CT data by Mechanical Finder (Research Center of Computational Mechanics Inc., Tokyo, Japan), software that creates FE models showing individual bone shape and density distribution. Equivalent stresses were analysed in zones 1 to 7 and compared to the DEXA data. FE studies revealed that there was no significant difference in equivalent stress between SL-PLUS MIA and SL-PLUS. BMD was maintained after THA in zones 3, 4, and 5, whereas BMD decreased in zones 2, 6, and 7. In zone 1, BMD decreased in SL-PLUS MIA stem group by 14%, while BMD was maintained in SL-PLUS standard stem.

Total Hip Arthroplasty (THA) is a well-established, cost-effective treatment for improving function and alleviating pain in patients who have disabling hip disease with excellent long-term results. Based on the excellent results, there is an ongoing trend for THA to be performed in younger and more active patients, having higher physical demands on their new total joints.

Polyethylene (PE) wear and its biological consequences are one of the main causes of implant failure in THA. Macrophages phagocytise PE wear particles and this will result in osteolysis and loss of periprosthetic bone. The risk of these complications can be estimated in relation to the amount of volumetric wear based on two assumptions: that the number of PE particles dispersed in the peri-prosthetic tissues is controlled by the amount of PE wear; and that the development of osteolysis and the resulting aseptic loosening is triggered by these PE particles. Based on these assumptions, a model was developed to estimate the osteolysis-free life of a THA, depending on the Linear Wear Rate (LWR) and femoral head size of the PE bearing.

A review of the literature was conducted to provide an estimate of the radiologic osteolysis threshold based on the volumetric wear of the PE bearing. This review demonstrates that this radiologic osteolysis threshold is approximated 670 mm3 for conventional PE. The osteolysis-free life of the THA was estimated by simply dividing this threshold volume by the annual Volumetric Wear Rate (VWR) of the bearing. The annual VWR is basically controlled by two parameters: (1) annual LWR and (2) head size, and was calculated by using published formulae.

For 28 mm heads, following osteolysis-free life was determined in function of the annual LWR. LWR: 10 µm/y => 116.6 years / LWR: 25 µm/y => 46.6 years / LWR: 50 µm/y => 23.3 years / LWR: 100 µm/y => 11.6 years. For 40 mm heads, following osteolysis-free life was determined in function of the annual LWR. LWR: 10 µm/y => 57.1 years / LWR: 25 µm/y => 22.9 years / LWR: 50 µm/y => 11.4 years / LWR: 100 µm/y => 5.7 years.

The osteolysis-free life determined by this model is in good agreement with the clinical results of PE bearings having a 28 mm head size and demonstrates that extreme low LWRs are mandatory to assure a descent osteolysis-free life for THA (PE bearings) using large heads, such as 40 mm. For such head sizes, small variations of the LWR may have large impacts on the osteolysis-free life of the THA.

Between January 1984 and January 1986, 131 porous-coated anatomic total hip replacements were performed in 119 consecutive patients. Of these, 100 patients (110 hips) who were alive at a minimum of 18 years after replacement were included in the study. The mean age of the patients at surgery was 48.4 years and that of surviving patients at the latest follow-up was 67.8 years. The mean duration of the clinical and radiological follow-up was 19.4 years (18 to 20).

The mean Harris hip score initially improved from 55 points before to 95 points at two years after operation, but subsequently decreased to 91 points after six years, 87 points after 11.2 years, and 85 points after 19.4 years. At the final follow-up, 23 hips (18%) of the entire cohort and 21% of survivors had undergone revision because of loosening or osteolysis of the acetabular component and eight hips (6%) of the entire cohort and 7% of survivors for loosening or osteolysis of the femoral component. Only four femoral components (4%) were revised for isolated aseptic loosening without osteolysis and two (2%) for recurrent dislocation. On the basis of these long-term results, the porous-coated anatomic femoral component survived for a minimum of 18 years after operation while the acetabular component was less durable. The findings identify the principles of uncemented joint replacement which can be applied to current practice.

Customization makes it possible to fulfill design requirements during MIS-THA procedures, and has helped define the parameters of fit and fill. This study describes the results of using customization techniques to develop a femoral implant for utilization.

CT-based design criteria for femoral implants has-been developed and used for primary, cement-less, non-minimally invasive THA surgery. Over 1000 procedures performed with these devices have been associated with displaced femoral fractures, and have been revised for septic loosening. This study has 2 parts:

20 implants were designed and implanted with CT-based criteria that utilized the identical fit and fill standards of the custom implants previously established, but had short (< 115 mm), tapered stems;

The stem of these implants was shortened (95–115 mm) and tapered. Implants in both groups were inserted using a single incision, posterior-lateral MIS approach. Patients were followed clinically and radiographically for six months. Immediate full weightbearing and use of a single cane were encouraged.

The use of CT-based customization techniques is helpful for defining design criteria of femoral implants, but the instrumentation for inserting these implants must be adapted to the specific surgery. Customization also facilitates the design and evaluation of CAOS applications for inserting these MIS implants.

Early reports on revision total hip arthroplasty (RTHA) suggested that outcomes of this procedure are as good as those of primary total hip arthroplasty (THA). However, RTHA is associated with longer surgery time, greater blood loss and increased risk of complications (thromboembolism, nerve injury, periprosthetic fractures, recurrent hip dislocations and infections). Aseptic loosening after RTHA was reported in 36% of patients aged over 55 years within 4 years after revision. Infections were reported in 32% and complications during surgery in 23% of patients respectively. Unsatisfactory results of RTHA stimulate the search for alternative procedures. Girdlestone excision arthroplasty (GA) seems to be a good solution for older patients with high risk of complications related to a poor general condition.

Material and method Between 2000 and 2003 we operated 39 patients, 10 for septic (26%) and 29 aseptic (74%) loosening of their THA. All patients complained of painful limb aggravated by weight bearing and the severity of pain was the main indication for the surgery. Average survival time of previous THA was 9 year (range: 1 to 20). We assessed pain, walking distance and the need to use walking aids. The outcomes were measured according to the Harris Hip Scale. The patients had the GA performed. The procedure involved removing implant and bone cement and placing the major trochanter into bone acetabulum. If an infection was present, an antibiotic irrigation system was introduced. No cast or braces were used and walking was started 2–7 days after surgery, depending on patients general condition.

Results Good pain control was reported by 33 (85%) patients. The average Harris Hip Score changed from 25 points preoperatively to 53 at latest follow-up. Average limb shortening was 4 centimetres (range: 2 to 8). Walking aids (one or two crutches) were required by all patients. Eighteen (46%) patients walked more than 500 m, 12 (31%) patients walked 200–500 m and 9 (23%) patients walked less than 200 m, of whom one patient was wheelchair bound.

Infection ceased in 9 cases, 1 patient died because of complications related to chronic infection.

Discussion GA yields satisfactory results in patients who have to have their prostheses removed. It provides a mobile, painless joint. The disadvantages of GA are: limb shortening and unstable gait which requires the use of crutches. This procedure should be indicated for patients with high risk of complications due to poor general health, infection and/or massive loss of bone stock which render more invasive procedures impossible. GA is also advisable in patients with weak hip abductor muscles, when RTHA is associated with a high risk of recurrent hip dislocation. The Girdlestone arthroplasty is a satisfactory salvage procedure in most cases of failed THA, when the choice of reimplantation exposes the patient to a high risk of further failure.

We report the clinical outcome and survival of 100 total hip arthroplasties with Link RS cementless hip prostheses after a mean of 63 months (51 to 93). The average preoperative Merle d'Aubigne hip score was 9.4 points and the average score at the latest follow-up was 15.3 points. Thirteen prostheses have been revised and seven await revision. Survivorship analysis based on intention to revise showed only 68% survival at seven years (95% CI 53% to 81%). The survivals of femoral and acetabular components verified to be loose at surgery were 78% and 89% respectively at seven years. A number of other patients have pain and it seems likely that there will be substantial reduction in these survival figures in the future.

Sixty-five total hip arthroplastics were reinserted after sepsis around the hip, positive cultures being obtained from fifty-six. Although 65 per cent of patients still have their implant in position, only sixteen of sixty-five (25 per cent) show an excellent or good result on a Harris rating. Twenty-three of sixty-five (35 per cent) subsequently required an excision arthroplasty. The indications and contraindications for this procedure are given.

We enrolled 98 patients (107 hips) with a mean age of 47 years (SD 8.6) into a prospective study of the Madreporic Lord THR; 34 hips had primary and 73 secondary osteoarthritis.

After ten years, the survival rate using revision as the endpoint for failure was 70% (±9) for the cup and 98% (±0.3) for the stem. The combined clinical and radiological survival rates were 46% (±11) and 81% (±10), respectively. Osteoporosis due to stress-shielding was observed in the proximal femur. Hips with radiologically dense bone postoperatively showed the most pronounced bone loss.

We recommend continued radiological follow-up of patients with this type of implant to allow revision to be performed before there is severe bony destruction of the pelvis.