Intra-articular fractures of the distal end of the radius in young adults

Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnar styloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.     

Bone-patellar ligament-bone and fascia lata allografts for reconstruction of the anterior cruciate ligament

A prospective study was performed of the first forty-seven consecutive patients who had repair of a ruptured anterior cruciate ligament and replacement with an allograft. Patients who had a rupture of another ligament were excluded, to provide a homogeneous group. Twenty-two patients received a fascia lata allograft and twenty-five patients received a bone-patellar ligament-bone allograft. All patients were enrolled in an exercise program to facilitate motion of the knee immediately after the operation, and all patients returned for postoperative evaluation (mean, forty months; range, twenty-five to sixty-seven months). The results were based on a comprehensive subjective and objective rating system, which assessed twenty factors. On testing with the KT-1000 arthrometer, 69 per cent of the patients had less than three millimeters of increased anterior-posterior displacement of the knee that had been operated on compared with the contralateral knee, 26 per cent had three to five millimeters, and 5 per cent had more than five millimeters. The knees that had a bone-patellar ligament-bone allograft had significantly lower values for anterior-posterior displacement than did those that had a fascia lata allograft (p less than 0.05). Just one patient, the only one in whom the fascia lata graft failed, had giving-way. There were no infections, and there was no evidence of rejection of the allograft or documented transmission of disease at the time of writing. A strict rating system was used. Eighteen patients (38 per cent) had an excellent result, twenty-four (51 per cent) had a good result, and five (11 per cent) had a fair or poor result. Motion of the knee immediately postoperatively was not deleterious to the allograft, and, because limitations of motion were identified and treated in the early postoperative period, full motion (0 to 135 degrees) was restored in all knees.     

Combined posterior incision and arthroscopic intra-articular repair of the meniscus. An examination of factors affecting healing

Using intra-articular techniques for meniscal repair, several factors associated with meniscal lesions were analyzed prospectively to determine their effects on healing of the repair. Although 260 medial or lateral meniscal repairs in 240 patients were done, 178 repairs in the 167 patients who were followed by postoperative arthroscopy or arthrography form the basis of this study. The results of the repairs were classified as healed, incompletely healed, or not healed. The average duration of follow-up was 100 weeks (range, twenty-eight to 231 weeks). By arthrographic or arthroscopic criteria, 61.8 per cent of the menisci healed, 16.9 per cent healed incompletely, and 21.3 per cent did not heal. Ninety-two per cent of the menisci were categorized as clinically stable, and 80 per cent of the patients returned to active sports participation. Positive correlations with healing were found in patients who had a narrow peripheral meniscal rim (zero to two millimeters) (p = 0.03) and in patients who had a repair that was associated with reconstruction of the anterior cruciate ligament (p = 0.0001).     

Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur

Thirty-seven fractures of the distal part of the femur in thirty-five patients were treated with interlocking intramedullary nailing. All fractures were nailed by a closed technique after any intercondylar extension of the fracture had been managed by reduction and stabilization with percutaneous lag-screws. Patients who had an isolated condylar fracture or a severely comminuted intercondylar fracture were treated with other types of implants. There were thirty extra-articular (type-A) fractures and seven intra-articular (type-C1 and type-C2) fractures. Postoperatively, early mobilization exercises and weight-bearing were begun. At an average duration of follow-up of 20.5 months (range, fifteen to twenty-six months), all thirty-seven fractures had healed. There were no malunions of either the supracondylar or the intercondylar fractures. Complications were infrequent and included chronic irritation from the distal screws in three patients and delayed union in one; the latter healed with two centimeters of shortening after bone-grafting. There were no infections. The functional results were assessed with the modified knee-rating system of The Hospital for Special Surgery. Thirteen knees (35 per cent) had an excellent result; twenty-two (59 per cent), a good result; and two (5 per cent), a fair result. The results correlated with the age of the patient and the presence of an intra-articular fracture. We concluded that closed interlocking intramedullary nailing is an excellent technique for both supracondylar and simple intercondylar fractures in which closed reduction and percutaneous fixation of the articular fracture is possible.     

Nutritional status: importance in predicting wound-healing after amputation

Protein-calorie malnutrition, or both, affects the morbidity and mortality of patients undergoing operations. Laboratory assessments of nutritional status consisting of evaluations of serum albumin levels and total lymphocyte counts are valid tests of a patient's nutritional status. In this study we examined the influence of preoperative nutritional status on morbidity in twenty-three diabetic patients who underwent a Syme amputation. All of the patients met Wagner's criteria for a Syme-level amputation, but in only 43 per cent (ten patients) did the amputation heal at this level, which was chosen by Wagner's criteria alone. Of the seven patients who, in addition to meeting Wagner's criteria, had a serum albumin level of at least 3.5 grams per deciliter and a total lymphocyte count of at least 1500 cubic millimeters, in six (86 per cent) the amputation healed at the Syme level. In contrast, the Syme-level amputation healed in only two of the eleven patients who met the criteria of Wagner but who had a serum albumin level of less than 3.5 grams per deciliter and a total lymphocyte count of less than 1500 cubic millimeters.     

Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament

The results of reconstruction of the anterior cruciate ligament with the central third of the patellar ligament as a free, autogenous, non-vascularized graft were retrospectively reviewed at our institution. Eighty reconstructions in seventy-nine patients were evaluated after a minimum of two years. In forty-eight (60 per cent) of the knees, the reconstruction was augmented with an extra-articular lateral sling of iliotibial band. The patients were evaluated with a physical examination, a KT-1000 arthrometer, radiographs, a subjective questionnaire, and a revision of the scale of The Hospital for Special Surgery for rating ligaments. Postoperatively, seventy-six (95 per cent) of the eighty knees no longer gave way, and the pivot-shift test was negative in sixty-seven (84 per cent) of the knees. The average score on the ligament-rating scale was 93 points. All of the patients who had clinical instability at the time of the most recent follow-up had associated ligamentous instability that had not been appreciated or addressed at the time of reconstruction. Arthrometric evaluation revealed that the laxity differed by three millimeters or less from that of the untreated knee in sixty (76 per cent) of the treated knees. In the patient who had bilateral reconstruction, the laxity was the same in both knees. Seventeen patients, who had more than three millimeters of translation, also had additional related ligamentous instability, most commonly posterolateral instability and insufficiency of the medial collateral ligament. We think that major associated ligamentous instability predisposes the reconstruction to failure and should be corrected in conjunction with the reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius

BACKGROUND: There is a paucity of data in the literature documenting the functional outcomes for patients who have been managed with a dorsal plate because of a distal radial fracture. The purpose of the present study was to determine the functional outcome and complications following dorsal plating for dorsally displaced, unstable fractures of the distal part of the radius. METHODS: The records of all patients who had been managed at our institution with dorsal plating because of a comminuted, dorsally displaced fracture of the distal part of the radius were reviewed. Patients with less than twelve months of follow-up were excluded from the study. Outcomes were evaluated at the time of the latest follow-up with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Gartland and Werley scoring system. RESULTS: Twenty-eight patients (nineteen women and nine men) with a mean age of forty-two years formed the basis of the study. The mean duration of follow-up was twenty-one months. Nineteen patients had been treated with a Synthes pi plate, and nine had been treated with a low-profile plate. There were no instances of loss of reduction, malunion, or nonunion. The mean score on the DASH questionnaire was 14.5 points. All patients had an excellent (nineteen patients) or good (nine patients) result according to the scoring system of Gartland and Werley. Nine patients had postoperative complications requiring repeat surgical treatment for hardware removal or extensor tendon reconstruction. All nine reoperations were performed in patients who had been treated with a Synthes pi plate, while none were performed in patients who had been treated with a low-profile plate (p < 0.025). Four complications occurred in patients who had been treated with a titanium plate, and five complications occurred in patients who had been treated with a stainless-steel plate (p = 0.71). CONCLUSIONS: Patients in whom a dorsally displaced distal radial fracture is treated with a titanium or stainless-steel Synthes pi plate have a significantly increased risk of complications compared with those in whom such a fracture is treated with a low-profile plate. Regardless of the type of plate used, all of the patients in the present study had a good or excellent long-term functional outcome.     

Fractures of the distal part of the fibula with associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament

The results in twenty-four patients who were treated for a distal fibular fracture and disruption of the deltoid ligament were studied, using subjective, objective, and radiographic criteria, over a period of at least two years. Nineteen (90 per cent) of the twenty-one patients who were treated without repair of the deltoid ligament had a good or excellent result. All but two of these patients were unrestricted in the ability to walk and run and had no pain during the activities of daily living. No patient had instability of the ankle. At follow-up, the range of motion of the ankle was within 15 degrees of that of the uninjured ankle in 90 per cent of the patients. Only one ankle had radiographic evidence of narrowing of the joint space. The three patients in whom the deltoid ligament was repaired did not have as good a result as the twenty-one patients in whom it was not, but this group was too small to permit valid comparisons. We concluded that exploration of the medial side of the ankle and repair of the deltoid ligament are not necessary unless reduction of the lateral malleolus fails to reduce the talus within the ankle mortise.     

A comparison of primary and revision total knee arthroplasty using the kinematic stabilizer prosthesis

The first 121 arthroplasties (in 105 patients) in which the cemented kinematic-stabilizer total knee prosthesis was used for primary arthroplasty or surgical revision at the Mayo Clinic were reviewed. Sixty-six patients (seventy-nine arthroplasties) were followed for a mean of thirty-seven months. There were fifty-three revision and twenty-six primary arthroplasties. The average range of motion in both groups increased from 95 to 101 degrees. Although none of these patients could ascend stairs without support before the operation, thirty-two (51 per cent) could do so at the time of the final follow-up. The incidence of moderate or severe pain was reduced from 86 to 6 per cent. Moderate or severe ligamentous instability had been present in thirty-three knees (42 per cent) preoperatively, but only five knees had significant medial, lateral, anterior, or posterior instability at final follow-up. The Hospital for Special Surgery knee score increased from an average of 56 points to 83 points in all of the knees. At follow-up, the patients who had had primary arthroplasty had 92 per cent good or excellent results and the patients who had had surgical revision had 81 per cent good or excellent results (p less than 0.05). There was no significant difference in the results between the patients who had osteoarthritis and those who had rheumatoid arthritis. Over-all, 85 per cent of the results were good or excellent at final follow-up. Tibial radiolucent lines of one to two millimeters were observed in 29 per cent of the knees at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Capitellocondylar total elbow replacement. A long-term follow-up study

The results of forty total elbow replacements in which a capitellocondylar prosthesis was implanted in thirty-five patients (five of whom had a bilateral procedure) were reviewed retrospectively. The average length of follow-up was 7.2 years (range, four to twelve years). Pronation, supination, and flexion of the elbow improved considerably, but extension did not change a great deal. The average rating of the elbow, according to the scoring system of Ewald et al., improved from 30 to 88 points, but the functional score, as defined by the American Rheumatism Association, improved in only four patients. Malarticulation or dislocation of the prosthesis occurred in ten patients (29 per cent). In two other patients, a deep infection developed, necessitating removal of the prosthesis. Ten prostheses (ten patients) had radiolucent lines on follow-up radiographs, but these lines were not associated with pain or loosening. Seven patients (seven elbows) had a transient ulnar-nerve palsy. The incidence of this complication was reduced from 30 per cent (five of seventeen patients) to 15 per cent (four of twenty-eight patients) when the lateral Kocher approach to the elbow was adopted.     

Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study.

In a ten-year study of the healing responses of thirty-one children with fresh fractures of the lateral condyle of the humerus with less than four millimeters of displacement, there were three patterns of healing. Forty-nine per cent healed rapidly in six weeks with abundant callus and periosteal new bone. Thirty-eight per cent healed slowly over eight to twelve weeks, mostly by endosteal union with little callus. Thirteen per cent had progressive displacement of the fragment in the plaster cast and required surgery to prevent non-union. Those fractures that healed had two millimeters or less of displacement of the fragment initially. Those that did not heal had an average of three millimeters of initial displacement. Established non-unions in good position that were symptomatic while the elbow was still immature were salvaged by bone-grafting, sparing the physis of the condylar fragment. The fragment united and grew with the elbow to maturity, producing an excellent end result on long-term follow-up. When the physeal plate of the ununited condylar fragment was absent, the fragment could not grow with the elbow and the result of surgery was less satisfactory.     

Results of compression-plating of closed Galeazzi fractures

Diaphyseal fractures of the distal third of the radius that are associated with disruption of the distal radio-ulnar joint accounted for eighty-four (6.8 per cent) of 1236 fractures in the forearm that were treated during a five-year period at the Los Angeles County-University of Southern California Medical Center. Thirty-six closed Galeazzi fractures, twenty-eight in male and eight in female patients, were followed for 1.5 to seven years after treatment using standard AO-compression plates with four to seven holes. Complications included seven injuries to the sensory or dorsal interosseous branch of the radial nerve, two infections, two non-unions, two re-fractures after plate removal, and shortening of the radius of five millimeters in one patient. The complication rate was 39 per cent. The average grip strength at follow-up was 71 per cent of the calculated normal value. The loss of strength was not related to use of a volar or dorsal surgical approach, the patient's age, or a delay of surgery for more than ten days after injury. The average loss of grip strength in the seven upper extremities with restricted motion of the wrist and forearm was 48 per cent, compared with an average loss of 29 per cent in the whole group. Of the twelve patients who were operated on more than ten days after injury, six had loss of motion at follow-up, compared with three who had such a loss among the twenty-four patients who were operated on within ten days after injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

The infected hip after total hip arthroplasty

We studied the cases of fifty-two patients with an infection at the site of a prosthetic total hip replacement, and are reporting the significant clinical features, infecting organisms, methods of treatment, and results at long-term follow-up. Forty-eight per cent of the hips had had an operation prior to the index arthroplasty, and 42 per cent had a wound complication. All patients had pain in the infected hip, but only 54 per cent had an erythrocyte sedimentation rate of more than thirty millimeters per hour, 44 per cent had fever, and 15 per cent had leukocytosis. In 88 per cent of the patients a single organism was grown on culture, and Staphylococcus epidermidis, Staphylococcus aureus, and Escherichia coli were present in about 75 per cent. When antibiotic therapy alone was the initial treatment, the infection was eradicated in only one patient. Excisional arthroplasty was the definitive surgical procedure in thirty-three patients and the infection was eradicated in twenty-seven of them, but the clinical result was satisfactory in only twenty. Of ten patients who had a true Girdlestone arthroplasty, none had recurrence of the infection and all had a clinically satisfactory outcome.     

Fractures in patients who have myelomeningocele

Thirty-seven (20 per cent) of 186 children who had myelomeningocele whose records were reviewed had sustained a total of seventy-six fractures. The frequency with which the fractures occurred was related directly to the level of neurological involvement. Thirteen (41 per cent) of the patients who had involvement at the thoracic level, fifteen (36 per cent) who had involvement at the upper lumbar level, eight (10 per cent) who had involvement at the lower lumbar level, and one (3 per cent) who had involvement at the sacral level sustained fractures. Sixty-five (86 per cent) of the fractures occurred before the child was nine years old, fifty-eight (76 per cent) were judged to be secondary to the limb being in a cast, and seventy-four (97 per cent) involved the lower extremity. Eleven patients, all of whom had thoracic or upper lumbar involvement, sustained fractures of multiple extremities. All fractures of the lower extremity were distal to the level of neurological involvement; they occurred predominantly in the femur in patients who had thoracic involvement and in the tibia in patients who had lumbar involvement. All of the metaphyseal and diaphyseal fractures healed satisfactorily, whether they were treated by immobilization in a plaster cast or in a bulky Webril dressing, although there were fewer complications in the latter group. The seven fractures that involved the physeal plate were a major problem, as three (43 per cent) had delayed union and two (29 per cent) developed premature growth arrest.     

Resurfacing of the knee with fresh osteochondral allograft

Fifty-nine fresh osteochondral allografts were consecutively transplanted into the knees of fifty-eight patients. The preoperative diagnoses were chondromalacia or degenerative arthritis of the patella, osteochondritis dissecans, a traumatic defect or osteonecrosis of the femoral condyle, a painful healed depressed fracture or traumatic defect of the tibial plateau, and unicompartmental traumatic arthritis of the knee. All of the patients had disabling pain after the failure of previous attempts to correct the problem surgically. Thirty-nine patients (forty knees) were available for follow-up at two to ten years after the allograft was transplanted. Nine transplants (22.5 per cent) failed and thirty-one (77.5 per cent) were successful. The result was rated excellent after thirteen of the successful transplants, good after fourteen, and fair after four. Transplantation of a fresh osteochondral allograft proved to be a satisfactory intermediate procedure for the treatment of the disabling conditions, except unicompartmental traumatic arthritis, in the young patients in this series. For the patients who had unicompartmental traumatic arthritis, the rate of success was only 30 per cent.     

Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications.

We reviewed the results of treatment of forty open diaphyseal fractures of the lower extremity in thirty-five children. The patients were between three and sixteen years old, and they had been managed between 1980 and 1988. The minimum duration of follow-up was one year. Eighty-six per cent of the patients had been injured in a motor-vehicle accident, and 74 per cent had associated injuries. Thirty-one of the fractures were Grade-II open or Grade-III open and seven were Grade-I open, according to the classification of Gustilo and Anderson. Two patients who had initially had a closed fracture were treated with a fasciotomy for a compartment syndrome, so these two fractures were included as open. Four other patients who had a Grade-II or III open fracture also needed a fasciotomy. All wounds were treated with immediate and repeat débridement and early soft-tissue coverage. Twenty-two fractures healed primarily. There were three early amputations. Twelve fractures that healed after six months were classified as delayed unions and three fractures were classified as non-unions because of the absence or arrest of healing, as seen on serial roentgenograms. Additional intervention was used to achieve union of eight of the fifteen fractures that had been classified as a delayed union or a non-union. Ten of the forty fractures were associated with infection, but osteomyelitis developed in only one patient. No patient had a growth arrest. Only one patient had a limb-length discrepancy that was more than two centimeters. Three early amputations and one delayed amputation were performed in patients who had a Grade-IIIC open fracture.     

Osteochondritis dissecans of the femoral condyles

Because the results of treatment of osteochondritis dissecans of the femoral condyles are still not consistently satisfactory, we reviewed the cases of eighty-three patients (ninety-five knees) with osteochondritis dissecans who were followed for two to thirty-one years to identify factors that may influence treatment and long-term prognosis. Of the eighty-three patients, sixteen had only non-surgical treatment, sixty-five had only surgical treatment, and two had non-surgical treatment of one knee and surgical treatment of the other. Of the twenty-two knees (eighteen patients) that were treated non-surgically, fifteen were treated before and seven were treated after distal femoral epiphyseal closure. Of the seventy-three knees (in sixty-seven patients) that were treated surgically because of persisting symptoms, twenty-three were treated before epiphyseal closure and fifty, after closure. At follow-up, each knee was given a rating of excellent, good, fair, poor, or failure, and a corresponding point score. Seventy-seven per cent of the knees in the surgical group and 82 per cent of those in the conservatively treated group were rated either excellent or good. The average scores in both groups were higher in knees in which the osteochondritic defect was small and was treated before epiphyseal closure, and in knees in which the fragment healed as compared with the ones from which the fragment was removed. We found that knees with osteochondritis dissecans of the femoral condyles that had no other abnormal physical findings or functional disability responded well to conservative treatment before epiphyseal closure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cemented total hip replacement in patients who are less than fifty years old

Forty-five cemented total hip replacements in thirty-eight patients who were less than fifty years old were followed with physical examinations and radiographs for five to eleven years (average, 7.3 years) after surgery. The average age of the patients at the time of surgery was 40.7 years. The average Iowa hip rating at follow-up was 91.9 points (range, 58 to 100 points). No surgical deaths, infections, or dislocations were encountered. All of the patients had been repeatedly advised to avoid running, jumping, heavy labor, and lifting more than forty pounds (eighteen kilograms). Revision of a prosthetic component was necessary in four hips (8.9 per cent); all of the revisions were successful. Radiolucent lines were seen about the acetabular components of thirty-one hips but in only three (6.6 per cent) were these judged to be progressive bone-cement demarcation lines. Only one of those three hips was symptomatic. Three hips (6.6 per cent) also had subsidence of the femoral component into the femoral canal, but only one hip was symptomatic. Resorption of the medial aspect of the proximal end of the femur was seen in five hips, the maximum resorption being three to five millimeters. I have concluded that cemented total hip arthroplasty can give acceptable results in patients who are thirty to fifty years old, and that the result can be reasonably long-lasting if the patients are willing to avoid strenuous activity.     

The use of tricorticocancellous bone graft in severely comminuted intra-articular fractures of the distal radius

PURPOSE: We report the results of a retrospective study of the use of tricorticocancellous iliac crest bone graft in 12 patients with acute AO type C3.2 or type C3.3 fractures of the distal radius who were followed up for at least 1 year. METHODS: Twelve of 17 patients treated with the protocol were available for follow-up evaluation. All fractures were treated with open reduction and combined internal and external fixation. Five fractures were plated dorsally, 1 volarly, and 5 volarly and dorsally. RESULTS: Five patients had AO type C3.2 fractures and 7 had AO type C3.3 fractures. Nine of 10 radiographic parameters that were restored to near-normal values during the surgery were maintained at near-normal levels at the final follow-up evaluation at a mean of 28 months after surgery. Nine fractures had less than 2 mm of articular step-off of the distal radius and 8 had less than 3 mm of total articular incongruity (gap plus step-off). In 10 patients the radial length was restored to at least 10 mm. The mean arc of flexion-extension was 67% and the mean grip strength was 57% of that of the uninjured side. According to the Gartland and Werley demerit-point system 5 of the patients had good or excellent results. According to the modified Green and O'Brien clinical rating system 2 patients had good or excellent results. Poor results for 2 patients according to the demerit-point system and for 6 patients according to the Green and O'Brien clinical rating system were associated with severe ipsilateral soft-tissue and osseous injuries of the wrist, forearm, and arm. The total articular incongruity had a moderately strong correlation with the outcome as assessed by the demerit-point system. CONCLUSIONS: Tricorticocancellous bone grafting in conjunction with combined internal and external fixation is a satisfactory treatment that can lead to a high rate of return to work and sports, a high level of patient satisfaction, and a low rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Early clinical experience with hydroxyapatite-coated femoral implants.

As part of a multi-center study, 238 titanium stems that were proximally coated with hydroxyapatite were implanted in 220 patients between January 1988 and December 1989. Ninety-two of these stems in eighty-three patients had a minimum of two years of follow-up, including analysis of the clinical and radiographic data. Clinically, the patients were essentially pain-free before six months and had a low (4 per cent) prevalence of pain in the thigh and a very high composite Harris hip-score (mean, 95 points) at two years. Radiographically, subsidence was detected in 8 per cent of the implants; no implant had more than three millimeters of subsidence. Radiolucencies were characteristically seen around the uncoated distal part of the stem, in 70 per cent of the implants. Contrastingly, radiolucencies were rare in the hydroxyapatite-coated proximal zones and were most often found anteriorly, in only 5 per cent of the implants. Areas of increased formation of cancellous bone were seen beneath femoral cortical bone at the interface between the hydroxyapatite-coated and uncoated parts of the stem, in 67 per cent of the implants. Calcar resorption was found in 49 per cent of the implants. Cortical thickening was present in 17 per cent of the implants at the uncoated distal part of the stem. Two of the 238 femoral implants were revised: one because of infection and one because of aseptic loosening associated with non-union of a subtrochanteric osteotomy.