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Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell. Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%). At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis. Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.

INTRODUCTION This paper describes, for the first time, the outcomes of patients undergoing total hip replacement for acute fractured neck of femur (#NOF) as recorded by the National Joint Registry of England and Wales (NJR). METHODS In the NJR we identified 1,302 of 157,232 Hospital Episode Statistics linked patients who had been recorded as having a total hip replacement for acute #NOF between April 2003 and November 2008. RESULTS The revision rate at five years for fully uncemented components was 4.1% (95% confidence interval [CI]: 2.2-7.3%), for hybrid it was 2.2% (95% CI: 0.9%-5.3%) and for fully cemented components 0.9% (95% CI: 0.4-2.0%). Five-year revision rates were increased for those whose operations were performed via a posterior versus a lateral approach. The Kaplan-Meier estimate of 30-day mortality was 1.4% (95% CI: 1.0-2.4%), which is over double the 30-day mortality rate for total hip replacement identified by the Office for National Statistics. The mean length of stay was also increased for those undergoing total hip replacements for #NOF compared with non-emergency indications. CONCLUSIONS Our data suggest that total hip replacements for acute #NOF give comparable results with total hip replacements for other indications.

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The pre-operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for prolapsed intervertebral disc were reviewed. Prolapse was recognised as bulging or sequestration of the disc with consequent root compromise. Measurement of the lumbar level of the interifiac line was shown to correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacraljunction was significantly higher than normal.A pathological value for the lumbosacral angle could not be identified.