This single-blinded randomised controlled trial investigated whether one design of mobile-bearing (MB) total knee replacement (TKR) has any advantage over a fixed-bearing (FB) design on long-term fixation as measured by radiostereometry. The amount of wear underneath the mobile bearing was also evaluated. A series of 42 knees was randomised to MB or FB tibial components with appropriate polyethylene inserts and followed for between ten and 12 years, or until the death of the patient. The polyethylene in the MB group was superior in that it was gamma-irradiated in inert gas and was calcium-stearate free; the polyethylene in the FB group was gamma-irradiated in air and contained calcium stearate. In theory this should be advantageous to the wear rate of the MB group. At final follow-up the overall mean migration was 0.75 mm (. sd. 0.76) in the MB group and 0.66 mm (. sd. 0.4) in the FB group, with the FB group demonstrating more posterior tilt and the MB group more internal rotation. In the FB group there was one revision for aseptic loosening, but none in the MB group. There were no significant differences in clinical or radiological scores. . For the MB group, the mean linear wear rate on the under-surface was 0.026 mm/year (. sd.  0.014). This was significantly smaller than the wear rate of 0.11 mm/year (. sd. 0.06) in the MB between femur and polyethylene (p < 0.001). Nevertheless, even in a best-case setting the mobile bearings of this TKR design had no apparent advantage in terms of fixation over the FB knee prosthesis at ten to 12 years. The wear underneath the mobile bearing was small and is unlikely to be clinically relevant

We report the long-term clinical follow-up and survivorship analysis of 40 distal femoral replacements performed between 1964 and 1980 for traumatic, locally aggressive and malignant conditions. Custom-made prostheses with fully-constrained knee joints were used to replace a mean of 42% of the length of the femur. Survivorship analysis showed a cumulative success rate of 80% at eight years, with no subsequent deterioration at 18 years. Clinical assessment revealed 78% excellent or good results. Failure was due to infection in three cases, and in two to fracture of a now-outmoded femoral stem

A retrospective review of medial compartment arthroplasty in 22 patients (22 knees) is reported. The operations were performed between 1973 and 1978. Eighty-six per cent were rated good or excellent using the knee rating system devised by the Hospital for Special Surgery, New York. Excellent or good results were achieved in six patients who had previously had a high tibial osteotomy. At the time of follow-up significant loosening had not occurred, although progression of patellofemoral disease was noted. This study supports the promising results reported for unicompartmental resurfacing arthroplasty in the elderly

Transposition of part of the pes anserinus was used to treat 96 knees in 78 patients with recurrent, habitual or permanent dislocations of the patella. The knees with habitual (48) and permanent (27) dislocations also had extensive release of superolateral contracture. The patients were reviewed at an average follow-up of 9 years 8 months. The medial stability of the patella had been improved in all the cases. There were no recurrences in 21 knees with recurrent dislocations. There were four recurrences (5.3%) in knees with habitual and permanent dislocations due to inadequate release of the superolateral contracture and incorrect transfer of the whole of the pes anserinus. Correction of these technical errors prevented further recurrence in all four cases

Correct positioning and alignment of components during primary total knee replacement (TKR) is widely accepted to be an important predictor of patient satisfaction and implant durability. This retrospective study reports the effect of the post-operative mechanical axis of the lower limb in the coronal plane on implant survival following primary TKR. A total of 501 TKRs in 396 patients were divided into an aligned group with a neutral mechanical axis (± 3°) and a malaligned group where the mechanical axis deviated from neutral by > 3°. At 15 years’ follow-up, 33 of 458 (7.2%) TKRs were revised for aseptic loosening. Kaplan-Meier survival analysis showed a weak tendency towards improved survival with restoration of a neutral mechanical axis, but this did not reach statistical significance (p = 0.47). We found that the relationship between survival of a primary TKR and mechanical axis alignment is weaker than that described in a number of previous reports

Of 37 consecutive patients suffering from tuberculosis of the lumbosacral spine, 26 were reviewed after an average follow-up of 20 years. Those presenting at under 10 years of age usually had a discharging sinus or a pointing abscess and a visible kyphosis. In older patients, low back pain was the predominant presenting symptom. Neurological involvement was uncommon. Both operative and conservative treatment had resulted in fusion but all patients treated conservatively ended up with a kyphosis associated with trunk shortening. They had a higher incidence of back pain and more complications in pregnancy. Anterior debridement and fusion with a strut graft can reduce the incidence and size of kyphosis, but is technically demanding. Treatment remains difficult and requires individual consideration

Most published randomised controlled trials which compare the rates of wear of conventional and cross-linked (XL) polyethylene (PE) in total hip arthroplasty (THA) have described their use with a cementless acetabular component. . We conducted a prospective randomised study to assess the rates of penetration of two distinct types of PE in otherwise identical cemented all-PE acetabular components. . A total of 100 consecutive patients for THA were randomised to receive an acetabular component which had been either highly XL then remelted or moderately XL then annealed. . After a minimum of eight years follow-up, 38 hips in the XL group and 30 hips in the annealed group had complete data (mean follow-up of 9.1 years (7.6 to 10.7) and 8.7 years (7.2 to 10.2), respectively). In the XL group, the steady state rate of penetration from one year onwards was -0.0002 mm/year (. sd. 0.108): in the annealed group it was 0.1382 mm/year (. sd. 0.129) (Mann–Whitney U test, p < 0.001). No complication specific to either material was recorded. These results show that the yearly linear rate of femoral head penetration can be significantly reduced by using a highly XLPE cemented acetabular component. Cite this article: Bone Joint J 2015;97-B:1458–62

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock

From 1983 to 1985 we performed 114 primary hip replacements in 108 consecutive osteoarthritic patients using a non-cemented RM isoelastic femoral stem. After a mean follow-up of 8.2 years, ten patients had died, 11 hips had been revised, six patients had been lost to follow-up and two had been excluded due to severe general illnesses. Of 85 arthroplasties (in 79 patients) 14 could not be assessed because of other illness or disability. The 71 remaining were reviewed by questionnaire and radiography; an excellent or good overall functional result was found in 31, 16 were fair and 24 were poor. Radiographically, 21 of 71 stems were judged to be loose and ten showed osteolytic foci, six of these without obvious loosening. We conclude that the isoelastic RM stem shows a high rate of loosening, but that this is not always associated with a poor subjective result. Regular radiographic review is necessary. The results are worse than those reported for other uncemented stems and for cemented stems

We report 12 patients with infiltrating muscular lipomas of the lower limbs all treated by wide resection. During follow-up averaging seven years, the tumour recurred in five patients. Our results and those reported by others suggest that, in order to avoid recurrence, this tumour, although benign, should be treated by total excision of the muscle or by compartmental resection. Hormonal imbalance was suspected in 9 of the patients but an oestrogen receptor analysis of the histological samples proved negative

In a prospective study, we evaluated the clinical results of 23 patients with a cryopreserved non-tissue-antigen-matched meniscal transplant at a follow-up of from two to five years. These early results were satisfactory in 20 patients. Three transplantations failed and the allografts were removed after 12, 20 and 24 months. Post-transplantation arthroscopy showed that most meniscal transplants had healed to the knee capsule. Histological examination showed revascularisation of the transplant and evidence of viable meniscal chondrocytes. The failures were probably caused by malalignment, resulting in impaired revascularisation of the graft

We have studied 29 patients for at least five years after canal-expansive laminoplasty for cervical spondylotic myelopathy. The short- and long-term clinical results were compared, and successive radiographs assessed. The long-term clinical outcome was excellent in five patients, good in 12, fair in 11 and poor in one. The mean short- and long-term improvements were 54.4% and 48.5% but patients with focal kyphotic, kyphotic and S-shaped cervical spines did less well, as did those who had a decrease in the index of curvature of the cervical spine of more than 10 at follow-up. Canal-expansive laminoplasty with reconstitution of the posterior soft tissues may help to prevent postoperative malalignment and late neurological deterioration

Stress shielding resulting in diminished bone density following total knee replacement (TKR) may increase the risk of migration and loosening of the prosthesis. This retrospective study was designed to quantify the effects of the method of fixation on peri-prosthetic tibial bone density beneath cemented and uncemented tibial components of similar design and with similar long-term survival rates. Standard radiographs taken between two months and 15 years post-operatively were digitised from a matched group of TKRs using cemented (n = 67) and uncemented (n = 67) AGC tibial prostheses. Digital radiograph densitometry was used to quantify changes in bone density over time. Age, length of follow-up, gender, body mass index and alignment each significantly influenced the long-term pattern of peri-prosthetic bone density. Similar long-term changes in density irrespective of the method of fixation correlated well with the high rate of survival of this TKR at 20 years, and suggest that cemented and uncemented fixation are both equally viable. Cite this article: Bone Joint J 2013;95-B:911–16

We have reviewed the results of 106 intertrochanteric osteotomies performed for osteonecrosis of the femoral head. The average age at operation was 47.5 years. At two years from operation 71% of the hips had a clinically satisfactory result and at final follow-up, an average of 8.2 years after operation, 58% continued to have excellent or good rating. Twenty-four hips had needed total replacement or arthrodesis because of pain. Patients aged less than 55 did better than those operated on after that age, and hips with an idiopathic or post-traumatic aetiology did considerably better than alcohol-induced or steroid-induced cases. In view of these findings we believe that in the younger adult, in the absence of metabolic bone disease or advanced joint destruction, intertrochanteric osteotomy should be considered for the treatment of osteonecrosis

This study compared the outcome of total knee replacement (TKR) in adult patients with fixed- and mobile-bearing prostheses during the first post-operative year and at five years’ follow-up, using gait parameters as a new objective measure. This double-blind randomised controlled clinical trial included 55 patients with mobile-bearing (n = 26) and fixed-bearing (n = 29) prostheses of the same design, evaluated pre-operatively and post-operatively at six weeks, three months, six months, one year and five years. Each participant undertook two walking trials of 30 m and completed the EuroQol questionnaire, Western Ontario and McMaster Universities osteoarthritis index, Knee Society score, and visual analogue scales for pain and stiffness. Gait analysis was performed using five miniature angular rate sensors mounted on the trunk (sacrum), each thigh and calf. The study population was divided into two groups according to age (≤ 70 years versus > 70 years). Improvements in most gait parameters at five years’ follow-up were greater for fixed-bearing TKRs in older patients (> 70 years), and greater for mobile-bearing TKRs in younger patients (≤ 70 years). These findings should be confirmed by an extended age controlled study, as the ideal choice of prosthesis might depend on the age of the patient at the time of surgery

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6 ± 8.4 points and the final mean JOA clinical score was 89.4 ± 12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0 ± 2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2 ± 7.9 points and the final score 84.0 ± 12.0 points. TRA was eventually carried out on four hips. Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients

We performed a prospective study in 186 patients with a minimum follow-up of two years in order to attempt to predict successful major re-implantation of the upper limb. There were 137 men and 49 women with 24 amputations of the palm, 75 of the wrist, 50 of the forearm, 9 disarticulations through the elbow, and 28 amputations through the upper arm. The degree of injury to the amputated segment and the stump were good predictors of the rate of success and the final outcome. Adequate preservation, contraction of the muscle in the amputated part after stimulation, the level of injury and a smoking habit were fair indicators, but the serum potassium concentration in the amputated segment was the best objective predictor. When it is higher than 6.5 mmol/l 30 minutes after re-perfusion, re-implantation should be avoided. A high systemic venous serum potassium concentration was also found before clinical signs of the re-perfusion syndrome were seen

Fifty-two children with 62 discoid lateral menisci were reviewed at an average follow-up of 5.5 years. Their average age at operation was 10.5 years and the mean delay in diagnosis was 24 months. Most of the children had vague and intermittent symptoms and the classical clunk was demonstrable in only 39% of the knees. An associated osteochondritis dissecans of the lateral femoral condyle was seen in seven knees. Forty-eight knees with symptomatic torn discoid menisci underwent open total lateral meniscectomy, six had arthroscopic partial meniscectomy and eight knees with intact discoid menisci, were left alone. Based on Ikeuchi's grading (Ikeuchi 1982), 37% of the knees had an excellent result, 47% had a good result and 16% had a fair result: none was poor. Arthroscopic partial meniscectomy is recommended only when the posterior attachment of the discoid meniscus is stable. A total meniscectomy is indicated for the Wrisberg-ligament type of discoid meniscus with posterior instability

We reviewed 236 of the 388 Chiari pelvic osteotomies performed between 1953 and 1967 at the Orthopaedic University Clinic of Vienna for the treatment of congenital dislocation and subluxation of the hip. Over 90% of the operations were performed by Chiari himself. Twenty-one hips had needed reoperation after an average of 15.4 years; the other 215 hips had been followed up for 20 to 34 years (mean 24.8). The overall clinical results were excellent or good in 51.4%, fair in 29.8% and poor in 18.3%. The results were worse with increasing age at operation. The Trendelenburg sign improved only in patients aged seven or less at operation, and range of movement decreased in all cases. Subjectively poor results were seen in patients with pre-operative signs of osteoarthritis. Radiological loss of correction during follow-up was seen only in cases with incomplete primary correction. The addition of an intertrochanteric varus osteotomy in 36 cases did not achieve either better centering or better development of the acetabular roof. Degenerative changes increased significantly during the long-term follow-up, but their progress seemed to have been slowed down by the osteotomy in the younger age groups. Indications and contra-indications for the operation are discussed

We investigated the factors related to the radiological outcome of a transtrochanteric curved varus osteotomy in patients with osteonecrosis of the hip. We reviewed 73 hips in 62 patients with a mean follow-up of 12.4 years (5 to 31.1). There were 28 men and 34 women, with a mean age of 33.3 years (15 to 68) at the time of surgery. The 73 hips were divided into two groups according to their radiological findings: group 1 showed progression of collapse and/or joint-space narrowing; group 2 had neither progressive collapse nor joint-space narrowing. Both of these factors and the radiological outcomes were analysed by a stepwise discriminant analysis. A total of 12 hips were categorised as group 1 and 61 as group 2. Both the post-operative intact ratio and the localisation of the necrotic lesion correlated with the radiological outcome. The cut-off point of the postoperative intact ratio to prevent the progression of collapse was 33.6%, and the cut-off point to prevent both the progression of collapse and joint-space narrowing was 41.9%. The results of this study indicate that a post-operative intact ratio of 33.0% is necessary if a satisfactory outcome is to be achieved after this varus osteotomy