This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage

We describe a technique for the diagnosis of loosening of the femoral component of the Oxford Unicompartmental Knee Replacement using accurately aligned lateral radiographs in extension and flexion. If gaps are present between the component and cement on one radiograph and not on the other, the component is loose

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications

1. A detailed study of density variations with age in cortical bone samples from different areas of the femoral diaphysis has been carried out. 2. Bone of relatively high density and, conversely, of low density was found to have a spiral pattern along the bone shaft. 3. Moving distally along the femoral shaft there was a transposition of the greatest density from the anterior to the posterior aspect. 4. In the erect body posture the femoral inclination is such that areas of denser bone might be expected to be aligned vertically because of the weight-bearing characteristics of the femur. 5. Most areas of the cortex tended to decrease in density after the age of fifty, the less dense areas changing more than those with an initial high density. Thus, osteoporosis tended not only to maintain but to accentuate the spiral pattern of density distribution by increasing the difference between dense and less dense bone. 6. In the distal region of the diaphysis bone resorption was greatest anteriorly but hardly affected the posterior aspect. A densitometric comparison between these two sites provided a clear indication of the effect of osteoporosis

Traditional techniques for the insertion of femoral stems in arthroplasty of the hip in osteopetrosis carry a considerable risk of penetration of the femoral cortex and intra-operative fractures, due to obliteration of the intramedullary cavity and greatly increased stiffness and brittleness of the bone. In order to reduce the risk of such complications we manufactured a customised stem and a computer-based guiding device for the preparation of a cavity within the proximal femur. This system was used successfully in three hips in two patients. We describe the system and the operative technique

We have investigated the accuracy of placement of the femoral component using imageless navigation in 100 consecutive Birmingham Hip Resurfacings. Pre-operative templating determined the native neck-shaft angle and planned stem-shaft angle of the implant. The latter were verified post-operatively using digital anteroposterior unilateral radiographs of the hip. The mean neck-shaft angle determined before operation was 132.7° (118° to 160°). The mean planned stem-shaft angle was a relative valgus alignment of 9.7° (. sd. 2.6). The stem-shaft angle after operation differed from that planned by a mean of 2.8° (. sd. 2.0) and in 86% of cases the final angle measured within ± 5° of that planned. We had no instances of notching of the neck or varus alignment of the implant in our series. A learning curve was observed in the time taken for navigation, but not for accurate placement of the implant. Navigation in hip resurfacing may afford the surgeon a reliable and accurate method of placement of the femoral component

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102° (20° to 120°) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%). There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis

1. Previous investigations into the blood supply of the femoral shaft are reviewed. 2. Details of the blood supply of the shaft of the femur in seventeen children under one year of age, and in ten adults, are given. 3. These findings are discussed with special reference to the fate of the femoral shaft after fracture or operation

We carried out 60 revision procedures for failed porous coated anatomic total knee replacements in 54 patients, which were divided into two groups. The 14 knees in group I had a well-fixed femoral component at surgery which was retained, and in the 46 knees in group II both tibial and femoral components were loose and were revised using a variety of implants. Our review comprised clinical and radiological assessment. A total of 13 knees required a second revision. Six (42%) in group I failed very early (mean 2.1 years) when compared with seven (15%) in group II (mean 6.8 years). Failure was due to wear of the polyethylene insert by the abraded, retained femoral component (crude odds ratio 4.07; 95% CI 1.07 to 15.5). We recommend a complete change of primary bearing surfaces at the time of revision of an uncemented total knee replacement in order to prevent early wear of polyethylene

Aims. Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF. Patients and Methods. We analysed data on 257 202 primary THAs with cemented stems and 390 linked first revisions for PF recorded in the National Joint Registry (NJR) of England, Wales and Northern Ireland to determine if a cemented femoral stem brand was associated with the risk of having revision for a PF after primary THA. All cemented femoral stem brands with more than 10 000 primary operations recorded in the NJR were identified. The four most commonly used cemented femoral stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem (n = 15 113) and Charnley (n = 20 182). We compared the revision risk ratios due to PF amongst the stems using a Poisson regression model adjusting for patient factors. Compared with the Exeter V40, the age, gender and ASA grade adjusted revision rate ratio was 3.89 for the cemented CPT stem (95% confidence interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to 1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70). Conclusions. The limitations of the study include incomplete data capture, analysis of only PF requiring revision and that observation does not imply causality. Nevertheless, this study demonstrates that the choice of a cemented stem may influence the risk of revision for PF. Cite this article: Bone Joint J 2016;98-B:1347–54

Children who present late with hip dislocation may require femoral osteotomy after reduction, to correct valgus and anteversion deformity of the femoral neck. After these procedures proximal femoral growth is unpredictable. We have studied proximal femoral growth in 40 children who had been treated by femoral osteotomy. Preoperatively, the mean femoral neck-shaft angle was 5° greater on the affected side than on the contralateral side. Postoperatively, it was 28° less. There was progressive recorrection; after five years the angle was not significantly different from that on the contralateral side. In our series 70% of the capital epiphyses became abnormally shaped, taking the appearance of a ‘jockey’s cap’. All the growth plates became angulated but this corrected with time. Correction of the neck-shaft angle probably results from the more normal mechanical environment provided by reduction. The abnormal radiographic appearance of the epiphysis and growth plate is probably due to the rotation produced by the osteotomy

We present the extended follow-up (≥ 20 years) of a series of fully hydroxyapatite-coated femoral components used in 72 primary total hip replacements (THRs). Earlier results of this cohort have been previously published. All procedures were performed between 1986 and 1991. The series involved 45 women and 15 men with 12 bilateral procedures. Their mean age at the time of surgery was 60 years (46 to 80) and the mean duration of follow-up was 22.5 years (20 to 25). At final follow-up, the mean Merle d’Aubigné and Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0) for pain, mobility and function, respectively. Of the patients 92% were very satisfied at the time of final follow-up. There were seven revisions: six of the acetabular component for aseptic loosening and one of both the stem and the acetabular component for loosening due to deep infection. The survival of this prosthesis at 22.5 years with revision for any reason as the endpoint was 91.7% (95% confidence interval (CI) 84 to 99). Survival with aseptic loosening of the stem as the endpoint was 100% (95% CI 90 to 100). This prosthesis provides pain relief in the long term. Survival of this component is comparable to the best results for primary THR with any means of fixation. Cite this article: Bone Joint J 2013;95-B:467–71

We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistant pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications

Radiostereometric analysis (RSA) can detect early micromovement in unstable implant designs which are likely subsequently to have a high failure rate. In 2010, the Articular Surface Replacement (ASR) was withdrawn because of a high failure rate. In 19 ASR femoral components, the mean micromovement over the first two years after implantation was 0.107 mm (. sd. 0.513) laterally, 0.055 mm (. sd. 0.204) distally and 0.150 mm (. sd. 0.413) anteriorly. The mean backward tilt around the x-axis was -0.08° (. sd. 1.088), mean internal rotation was 0.165° (. sd. 0.924) and mean varus tilt 0.238° (. sd. 0.420). The baseline to two-year varus tilt was statistically significant from zero movement, but there was no significant movement from one year onwards. We conclude that the ASR femoral component achieves initial stability and that early migration is not the mode of failure for this resurfacing arthroplasty

We present a retrospective series of 170 cemented titanium straight-stem femoral components combined with two types of femoral head: cobalt-chromium (CoCr) alloy (114 heads) and alumina ceramic (50 heads). Of the study group, 55 patients (55 stems) had died and six (six stems) were lost to follow-up. At a mean of 13.1 years (3 to 15.3) 26 stems had been revised for aseptic loosening. The mean follow-up time for stable stems was 15.1 years (12.1 to 16.6). Survival of the stem at 15 years was 75.4% (95% confidence interval (CI) 67.3 to 83.5) with aseptic failure (including radiological failure) as the end-point, irrespective of the nature of the head and the quality of the cement mantle. Survival of the stem at 15 years was 79.1% (95% CI 69.8 to 88.4) and 67.1% (95% CI 51.3 to 82.9) with the CoCr alloy and ceramic heads, respectively. The quality of the cement mantle was graded as a function of stem coverage: stems with complete tip coverage (type 1) had an 84.9% (95% CI 77.6 to 92.2) survival at 15 years, compared with those with a poor tip coverage (type 2) which had a survival of only 22.4% (95% CI 2.4 to 42.4). The poor quality of the cement mantle and the implantation of an alumina head substantially lowered the survival of the stem. In our opinion, further use of the cemented titanium alloy straight-stem femoral components used in our series is undesirable

We reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54). The mean modified Harris hip score improved by 19.2 points (95% confidence interval 13.6 to 24.9; p < 0.001) while the mean non-arthritic hip score improved by 15.0 points (95% confidence interval 10.9 to 19.1, p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The overall level of satisfaction was high with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred. Arthroscopic femoral osteochondroplasty performed in selected patients over 60 years of age, who have hip pain and mechanical symptoms resulting from cam femoroacetabular impingement, is beneficial with a minimal risk of complications at a mean follow-up of 30 months

Concerns have been reported to the United Kingdom National Patient Safety Agency, warning that cementing the femoral component during hip replacement surgery for fracture of the proximal femur may increase peri-operative mortality. . The National Hip Fracture Database collects demographic and outcome data about patients with a fracture of the proximal femur from over 100 participating hospitals in the United Kingdom. We conducted a mixed effects logistic regression analysis of this dataset to determine whether peri-operative mortality was increased in patients who had undergone either hemiarthroplasty or total hip replacement using a cemented femoral component. A total of 16 496 patients from 129 hospitals were included in the analysis, which showed a small but significant adjusted survival benefit associated with cementing (odds ratio 0.83, 95% confidence interval 0.72 to 0.96). Other statistically significant variables in predicting death at discharge, listed in order of magnitude of effect, were gender, American Society of Anesthesiologists grade, age, walking accompanied outdoors and arthroplasty. Interaction terms between cementing and these other variables were sequentially added to, but did not improve, the model. . This study has not shown an increase in peri-operative mortality as a result of cementing the femoral component in patients requiring hip replacement following fracture of the proximal femur

The role of vacuum mixing on the reduction of porosity and on the clinical performance of cemented total hip replacements remains uncertain. We have used paired femoral constructs prepared with either hand-mixed or vacuum-mixed cement in a cadaver model which simulated intra-operative conditions during cementing of the femoral component. After the cement had cured, the distribution of its porosity was determined, as was the strength of the cement-stem and cement-bone interfaces. The overall fraction of the pore area was similar for both hand-mixed and vacuum-mixed cement (hand 6%; vacuum 5.7%; paired t-test, p = 0.187). The linear pore fractions at the interfaces were also similar for the two techniques. The pore number-density was much higher for the hand-mixed cement (paired t-test, p = 0.0013). The strength of the cement-stem interface was greater with the hand-mixed cement (paired t-test, p = 0.0005), while the strength of the cement-bone interface was not affected by the conditions of mixing (paired t-test, p = 0.275). The reduction in porosity with vacuum mixing did not affect the porosity of the mantle, but the distribution of the porosity can be affected by the technique of mixing used

We performed a series of 16 anatomical dissections on Caucasian cadaver material to determine the surgical anatomy of the medial femoral circumflex artery (MFCA) and its anastomoses. These confirmed that the femoral head receives its blood supply primarily from the MFCA via a group of posterior superior nutrient arteries and the posterior inferior nutrient artery. In terms of anastomoses that may also contribute to the blood supply, the anastomosis with the inferior gluteal artery, via the piriformis branch, is the most important. These dissections provide a base of knowledge for further radiological studies on the vascularity of the normal femoral head and its vascularity after dislocation of the hip