The Harris-Galante porous-coated, hemispherical, polyethylene-lined acetabular component in patients under 50 years of age: a 12- to 16-year review.

We have reviewed 70 Harris-Galante uncemented acetabular components implanted as hybrid hip replacements with cemented stems between 1991 and 1995 in 53 patients whose mean age was 40 years (19 to 49). The mean follow-up was for 13.6 years (12 to 16) with no loss to follow-up. We assessed the patients both clinically and radiologically. The mean Oxford hip score was 20 (12 to 46) and the mean Harris hip score 81 (37 to 100) at the final review. Radiologically, 27 hips (39%) had femoral osteolysis, 13 (19%) acetabular osteolysis, and 31 (44%) radiolucent lines around the acetabular component. Kaplan-Meier survival curves were constructed for the outcomes of revision of the acetabular component, revision of the component and polyethylene liner, and impending revision for progressive osteolysis. The cumulative survival for revision of the acetabular component was 94% (95% confidence interval 88.4 to 99.7), for the component and liner 84% (95% confidence interval 74.5 to 93.5) and for impending revision 55.3% (95% confidence interval 40.6 to 70) at 16 years. Uncemented acetabular components with polyethylene liners undergo silent lysis and merit regular long-term radiological review.

A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability.

Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and is an important contributory factor to patellofemoral instability and recurrent dislocation. We studied prospectively a series of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, who were treated by a trochleoplasty by a single surgeon between June 2002 and June 2007. Pre- and post-operative scores were assessed by the patients and a satisfaction questionnaire was completed. Of the 54 patients (59 knees) in the series, 39 (44 knees) were female and 15 (15 knees) were male. Their mean age at surgery was 21 years and 6 months (14 years 4 months to 33 years 11 months). In 40 patients (42 knees) the mean follow-up was for 24 months (12 to 58). One patient was unable to attend for follow-up. An analysis of the results of those patients followed up for at least 12 months showed a statistically significant improvement in outcome (p < 0.001 for all scores). Overall, 50 patients (92.6%) were satisfied with the outcome of their procedure. The early results of trochleoplasty are encouraging in this challenging group of patients.

Is anterior knee pain a predisposing factor to patellofemoral osteoarthritis?

Adolescent anterior knee pain has traditionally been described as running a benign and self-limiting course. Studies more recently have questioned this supposition. This study aimed to assess how many patients who had undergone patellofemoral arthroplasty for isolated patellofemoral arthritis had previously suffered from adolescent anterior knee pain, knee instability and trauma. This group was then compared to a control group of medial unicompartmental arthroplasty patients. Both groups were surveyed by postal questionnaire, with a >75% response rate from each group. 22% of the patellofemoral arthroplasty group described adolescent or early adulthood anterior knee pain as compared to 6% in the medial unicompartmental arthroplasty group (p<0.001). Patients in the patellofemoral group had also suffered significantly more patellofemoral instability and trauma than the medial unicompartmental group (p<0.001 and p=0.02, respectively). A significant number of patients with patellofemoral arthritis have described preceding anterior knee pain in their adolescence and early adult years, raising the question as to whether anterior knee pain may be one of the contributing factors to patellofemoral osteoarthritis in later years.

Customised hinged knee replacements as a salvage procedure for failed total knee arthroplasty.

BACKGROUND: Failure of knee arthroplasty can lead to significant pain and functional disability. In a small number of patients with fracture, sepsis or massive bone loss they are considered for arthrodesis or above knee amputation. The purpose of this study was to investigate the results and complications of using customised hinged knee replacements in their place. METHODS: Since 1993, 30 of the 280 (10.7%) revision knee replacements in the Avon Orthopaedic Centre, Bristol have used Endo customised hinged knee prostheses (21 rotating, nine fixed) for salvage of limb threatening situations in elderly patients. Surgical indications were 22 low periprosthetic fractures (with or without aseptic loosening), five massive aseptic osteolyses, and three deep infections. RESULTS: The mean length of post-operative hospital stay was just 14.6 days and all patients were discharged walking with aids. At follow up (mean 3.0 years, range 0.5-9.3 years) nine patients had died with their prostheses in situ and functioning. Six patients developed deep sepsis, two of which underwent above knee amputation, and two had received further surgery for septic problems. Two patients required further surgery for prosthetic disarticulation and one patient had successful on table vascular repair. Twenty-five patients had mid- or long- term follow up. Their mean American Knee scores (AKS) were 69.8 for knee and 35.6 for function (maximum 100), with mean total knee flexion 83 degrees. Mean Oxford knee scores (OKS) and WOMAC scores (both scored between 12 and 60 with low score indicating less difficulties) were 34.0 and 30.5, respectively. CONCLUSIONS: Customised hinge revision knee replacements gave rapid rehabilitation and hospital discharge. Complications were high but at mid- and long-term review, no prostheses had failed from an aseptic cause and most of the knees of this challenging group were providing both stability and flexion.

Consultation skills of medical students before and after changes in curriculum.

The University of Manchester Medical School has adopted problem-based learning as its main educational method, with a change of emphasis from a biomedical to a biopsychosocial approach. The training of junior medical students in clinical interviewing is intended to reinforce and develop their interpersonal skills. We measured the impact of this new curriculum by assessing two intakes of students covering the period before and after its introduction; a third intake was later added to examine the effect of further curriculum adjustments. 86 students, randomly selected, were videorecorded conducting diagnostic interviews with standardized patients 10 weeks after they had started to learn clinical interviewing. Two instruments were developed--a 23-item communication skills scale and a 13-item information-gathering scale and both showed acceptable inter-rater and test-retest reliability. Communication skills did not differ between years. The total score for information-gathering fell by 13% (95% confidence interval -20 to -6%, P < 0.001) in the first year after introduction of the new educational approach but returned to baseline the following year after further modification of the course. Although the new approach yielded no measurable improvement in the process of communication, assessment 10 weeks after the start of interview training may be too early to permit definitive conclusions. We conclude that it is possible to change to a more patient-centred emphasis in teaching medical interviewing. Some initial loss of information content was rectified by adjustment of the course. Our unfavourable early experience highlights the need to evaluate educational change.