 TRAUMA

A randomized controlled trial of cemented

versus cementless arthroplasty in patients
with a displaced femoral neck fracture
A FOUR-YEAR FOLLOW-UP
B. Barenius, Aims
C. Inngul, The aim of this study was to compare the functional and radiological outcomes in patients
Z. Alagic, with a displaced fracture of the hip who were treated with a cemented or a cementless
A. Enocson femoral stem.

From Stockholm South Patients and Methods

General Hospital, A four-year follow-up of a randomized controlled study included 141 patients who
Stockholm, Sweden underwent surgery for a displaced femoral neck fracture. Patients were randomized to
receive either a cemented (n = 67) or a cementless (n = 74) stem at hemiarthroplasty (HA;
n = 83) or total hip arthroplasty (THA; n = 58).

Results
Early differences in functional outcome, assessed using the Harris Hip Score, the Short
Musculoskeletal Functional Assessment score and EuroQol-5D, with better results in
cemented group, deteriorated over time and there were no statistically significant
 B. Barenius, MD, PhD, differences at 48 months. Two (3%) patients in the cemented group and five (6.8%) in the
Consultant Orthopaedic cementless group underwent further surgery for a periprosthetic fracture. This difference
Surgeon
 C. Inngul, MD, PhD, was statistically significant (p = 0.4). No patient underwent further surgery for instability or
Consultant Orthopaedic infection between one and four years postoperatively. The mortality and the radiological
Surgeon
Department of Clinical Science outcomes were similar in both groups.
and Education,
Södersjukhuset, Karolinska
Institute, Unit of Orthopaedics, Conclusion
Stockholm South General Patients with a displaced femoral neck fracture treated with an arthroplasty using a
Hospital, Stockholm, Sweden.
cemented or cementless stem had good function and few complications up to four years
 Z. Alagic, MD, Radiologist
Department of Molecular
postoperatively. However, due to the poor short-term functional outcomes in the
Medicine and Surgery, Unit of cementless group, the findings do not support their routine use in the treatment of these
Diagnostic Radiology,
Karolinska University Hospital,
elderly patients.
Karolinska Institute,
Stockholm, Sweden.
Cite this article: Bone Joint J 2018;100-B:1087–93.
 A. Enocson, MD, PhD,
Consultant Orthopaedic
A displaced femoral neck fracture in an elderly complications in the short term.9,11,13,14,16-18
Surgeon patient is a life-threatening injury. Primary However, there is a higher incidence of
Department of Clinical Science
and Education,
operative treatment with an arthroplasty as soon as periprosthetic fractures when using cementless
Södersjukhuset, Karolinska possible after the injury has proven satisfactory stems.9,19,20 Although most studies support the use
Institute, Unit of Orthopaedics,
Stockholm South General
outcomes in several studies. Most patients regain of a cemented stem, few have compared cemented
Hospital, Stockholm, Sweden good or acceptable function and pain relief, whether and cementless stems beyond two years.
and Department of Molecular
Medicine and Surgery, Unit of
a hemiarthroplasty (HA) or a total hip arthroplasty The aim of this study was to investigate the
Orthopaedics, Karolinska (THA) is used.1-3 The risk of complications and mid-term outcomes, including the need for further
University Hospital, Karolinska
Institute, Stockholm, Sweden.
mortality is, however, high.4,5 One risk factor for surgery, function, health-related quality of life
cardiopulmonary events is fat embolism from the (HRQoL), and radiological appearance in elderly
Correspondence should be sent
to B. Barenius; email: femoral canal when using a cemented stem.6,7 This patients with a femoral neck fracture treated with
bjorn.barenius@ki.se risk is reduced by using a cementless stem. A arthroplasty, comparing a cemented with a
©2018 The British Editorial number of authors have compared cemented and cementless stem.
Society of Bone & Joint Surgery cementless stems in these patients.8-15 In some, the
do:10.1302/0301-620X.100B8.
BJJ-2017-1593.R1 $2.00 stems performed similarly,8,10,12,15 whereas in Patients and Methods
others, cemented stems performed better in Between October 2009 and April 2013, 964
Bone Joint J
2018;100-B:1087–93. restoring function and pain relief with fewer patients with a displaced femoral neck fracture

VOL. 100-B, No. 8, AUGUST 2018 1087

1088 B. BARENIUS, C. INNGUL, Z. ALAGIC, A. ENOCSON
Table I. Baseline data for all patients (n = 141) in relation to the type of stem used
Mean age, yrs (range)
Mean cognitive function, SPMSQ score (range)
Female gender, n (%)
ASA33 class 1 or 2, n (%)
Mobility: no walking aid or just one stick, n (%)
ADL n in Katz group A, n (%)*
Hemiarthroplasty, n (%)
Total hip arthroplasty, n (%)
At 24-mth follow-up
Age, mean (range)
Gender, female n (%)
At 48-mth follow-up
Age, mean (range)
Gender, female n (%)
*Katz group A, totally independent in all activities of daily living
SPMSQ, Short Portable Mental Status Questionnaire; ASA, American Society of Anesthesiologists; ADL, activities
of daily living
(Garden grade 3 or 4)21 were treated at the unit of Orthopaedics,
Stockholm South General Hospital. Inclusion criteria for the
study were: age ≥ 65 years old, living and moving
independently (with or without walking aids) and without drug
or alcohol abuse. The trauma also had to be low-energy and the
patients had to be without severe cognitive dysfunction, thus
able to give > three correct answers on the Short Portable
Mental Status Questionnaire.22 Patients with symptomatic
osteoarthritis, rheumatoid arthritis or trauma > 48 hours before
admission were excluded. A total of 141 patients fulfilling these
criteria gave written consent and were included. Randomization
was performed using sealed envelopes. This was originally
designed as two studies with a cutoff between the studies at the
age of 80 years. Due to slow recruitment, the decision was made
in November 2012 to pool all patients into one study. Patients
aged between 65 and 79 years were allocated to a cemented or
reversed hybrid THA, while patients aged > 80 years were
allocated to a cemented or cementless unipolar HA.
All operations were performed by a group of 14 orthopaedic
surgeons who were experienced in both techniques. A routine
direct lateral approach was used with the patient in a lateral
decubitus position.23 The components used in the cemented
group were an Exeter stem (Stryker, Kalamazoo, Michigan)
with a unipolar head in patients undergoing HA and a 32 mm
head and a cross-linked polyethylene (XLPE) Marathon cup
(DePuy Synthes, Warsaw, Indiana) in those undergoing THA.
For the cementless group, a hydroxyapatite-coated Bimetric
stem (Zimmer Biomet, Warsaw, Indiana) was used with a
unipolar head for those undergoing HA and a 32 mm head and
the same type of acetabular component as in the cemented group
for those undergoing THA. Gentamicin-loaded Optipac
(Zimmer. Biomet, Warsaw, Indiana) cement was used for all
cemented components. Antibiotic prophylaxis involved three
doses of intravenous Cloxacillin 2 g given between 30 and 60
minutes before surgery, and three and six hours after the first
dose. Surgery was performed under spinal anaesthesia, if
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Cemented stem (n = 67) Cementless stem (n = 74)
81.2 (65 to 96) 81.3 (66 to 93)
9.3 (5 to 10) 9.0 (6 to 10)
46 (69) 53 (72)
35 (52) 32 (43)
56 (84) 57 (77)
63 (94) 66 (89)
39 (58) 44 (60)
28 (42) 30 (41)
(n = 53) (n = 53)
82.3 (68 to 99) 82.8 (68 to 95)
37 (49) 38 (51)
(n = 43) (n = 43)
84.4 (69 to 99) 83.6 (71 to 94)
31 (49) 32 (51)
possible, and all patients received thromboembolic prophylaxis
with low molecular heparin (4500 IU Tinzaparin) for 30 days
with the first dose being given on the evening after the surgery.
Primary assessment. Preoperatively, self-administered ques-
tionnaires regarding living conditions, activities of daily living
(ADL),24 health-related quality of life (EuroQol(EQ)-5D),25 and
the Short Musculoskeletal Function Assessment questionnaire
(SMFA)26 were completed with the help of a research nurse, to
include information that the patients could recall for the week
before the fracture. Patients were reviewed four, 12, 24 and 48
months postoperatively. The results from the four- and 12-month
reviews have been published in this journal.11 At each review, a
research nurse collected the EQ-5D and SMFA scores. An ortho-
paedic surgeon recorded the Harris Hip Score (HHS).27 Compli-
cations were recorded as described by the patients and from the
medical records if a complication was treated at another hospital.
Radiographic outcome. An anteroposterior (AP) view of the
pelvis and AP and lateral views of the hip were obtained before
and after surgery, and at the time of the routine reviews. A
radiologist (ZA) reviewed all the radiographs. The proximal
femoral bone stock was classified according to Dorr (type A, B, or
C).28 Heterotopic ossification (HO) was graded as described by
Brooker et al,29 and acetabular erosion in the HA group was
assessed as described by Baker et al.30 Significant radiological
loosening of either the acetabular or femoral component was
defined as a radiolucent zone of > 2 mm around the whole
component.31 Significant subsidence of the stem was defined as
> 5 mm.32
Statistical analysis. A power analysis was performed after
pooling the two original studies. This indicated that 140 patients
were needed at the 12-month review, assuming 10% mortality,
to detect a five-point difference in HHS, with 80% power and a
5% level of significance. The intention-to-treat principle was
used in the analysis. Analysis was performed using the IBM
SPSS 22.0 software package for Macintosh (IBM Corp.,
Armonk, New York). Nominal variables were tested by chi-
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 A RANDOMIZED CONTROLLED TRIAL OF CEMENTED VERSUS CEMENTLESS ARTHROPLASTY 1089

964 patients eligible for inclusion

Excluded
Cognitive dysfunction, mental illness, or language barrier (n = 279)
No available study surgeon (n = 185)
Not fit enough for arthroplasty surgery (n = 81)
Fracture older than 48 hours (n = 53)
Not independent walking or living (n = 51)
Missed study cases (n = 40)
Pathological fractures (n = 37)
Declined to participate (n = 36)
Other reasons (n = 61)

Included (n = 141)

Cemented (n = 67) Cementless (n = 74)

Randomized Randomized Randomized Randomized

THA (n = 28) HA (n = 39) THA (n = 30) HA (n = 44)

Treatment Treatment
Treatment Treatment
HA (n = 38) Cementless HA (n = 41)
THA (n = 28) THA (n = 30)
ORIF (n = 1) Cemented HA (n = 3)

Deceased (n = 2) Deceased (n = 7) Deceased (n = 3) Deceased (n = 7)

Lost to follow-up (n = 0) Lost to follow-up (n = 5) Lost to follow-up (n = 2) Lost to follow-up (n = 9)

Available at 24-mth Available at 24-mth Available at 24-mth Available at 24-mth

follow-up (n = 26) follow-up (n = 27) follow-up (n = 25) follow-up (n = 28)

Deceased (n = 6) Deceased (n = 10) Deceased (n = 6) Deceased (n = 14)

Lost to follow-up (n = 1) Lost to follow-up (n = 7) Lost to follow-up (n = 2) Lost to follow-up (n = 9)

Available at 48-mth Available at 48-mth

Available at 48-mth Available at 48-mth
follow-up (n = 21) follow-up (n = 22)
follow-up (n = 22) follow-up (n = 21)

1 phone interview only 1 phone interview only

3 questionnaires only
1 questionnaire only

Fig. 1

Flowchart of all the patients. THA, total hip arthroplasty; HA, hemiarthroplasty; ORIF, open reduction and internal fixation.

squared test or Fisher’s exact test. Ordinal variables and non-
normality distributed interval and ratio scale variables were
evaluated by the Mann–Whitney U test. The tests were two-
sided and the results were considered significant at p < 0.05.
Ethical approval. The study was approved by the local ethics
committee (2009/1188-3/1 and 2013/412-32) and was
registered at www.clinicaltrials.gov (NCT 01798472).
Results
A total of 141 patients were included, and 67 patients were
randomized to a cemented, and 74 to a cementless stem.
At the final follow-up after four years, 86 patients were
alive and willing to participate. The baseline data of the
patients are shown in Table I and a flowchart of the study in
Figure 1.
Mortality and adverse events. Since the review, 12 months
postoperatively, 25 patients had died at 48 months. The
mortality 24-months postoperatively was 13% (9/67) in the
cemented group and 14% (10/74) in the cementless group
(p = 1.0). The mortality 48 months postoperatively was 24%
(16/67) in the cemented group and 28% (20/74) in the
cementless group (p = 0.8). Seven patients, (two of 67 (3%)
in the cemented group and five of 74 (6.8%) in the
cementless group) underwent further surgery due to a
periprosthetic fracture, between 12 and 48 months
postoperatively (p = 0.4). One patient with a cemented HA
underwent conversion to a THA after 12 months due to
acetabular erosion. No patient required further surgery due to
dislocation or infection after 12 months. Details on adverse
events are shown in Table II.

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1090 B. BARENIUS, C. INNGUL, Z. ALAGIC, A. ENOCSON

Table II. Adverse events between 12 and 24 months follow-up.

Adverse event Cemented stem Cementless stem

Reoperation due to periprosthetic fracture, n (%) 2 (3.0) 5 (6.8)
Revision to total hip arthroplasty, n (%) 1/26 (3.8)* 0 (0)
Trendelenburg limp, n (%) 1 (1.5) 3 (4.1)
Trochanteric pain, n (%) 2 (3.0) 0 (0)
*Proportion calculated according to the 26 patients with cemented HA that were assessed at the
12-month follow-up

Cemented Cementless Cemented Cementless

1.2
1.2

1
1

0.8
0.8

0.6 0.6

0.4 0.4

0.2 0.2

0 0
Pre-injury 4 mths 12 mths 24 mths 48 mths Pre-injury 4 mths 12 mths 24 mths 48 mths
(N/S) (p = 0.001) (p < 0.001) (p = 0.02) (N/S) (N/S) (p = 0.09) (p = 0.01) (N/S) (N/S)
Fig. 2a Fig. 2b

Cemented Cementless

1.2

0.8

0.6

0.4

0.2

0
Pre-injury 4 mths 12 mths 24 mths 48 mths
(N/S) (p = 0.09) (p = 0.01) (N/S) (N/S)
Fig. 2c

a) Graph showing the mean EuroQol-5D (EQ-5D)scores for all patients (a) those undergoing a hemiarthoplasty (b) and total hip arthroplasty (c).
N/S, not significant.

Functional outcome. Apart from a higher mean total HHS in
the cemented group after four months and a higher mean HHS
pain subscore at 24 months for the cemented group, the groups
had similar HHS at all follow-ups. The mean SMFA scores in
the cemented group were better for dysfunction and/or bother
scores at the early follow-ups compared with the cementless
group, but the scores deteriorated for the cemented group and at
the final follow-up the scores were similar. The functional
outcome scores are shown in Table III. HRQoL assessed by EQ-
5D is shown in Figure 2. The results were statistically better in
the cemented group for the first 24 months, but were similar in
both groups thereafter (Fig. 2a). Additional results in the
subgroups of patients who underwent a HA and THA are shown
in Figs. 2b and 2c, respectively, and although there remained a
visible difference between groups in the THA subgroup at 48
months, this difference was not statistically significant.

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 A RANDOMIZED CONTROLLED TRIAL OF CEMENTED VERSUS CEMENTLESS ARTHROPLASTY 1091

Table III. Functional outcome by Harris Hip Score (HHS) and Short Musculoskeletal Function Assessment (SMFA) score

Functional outcome n Cemented stem Cementless stem p-value*

Mean HHS score, total (SD)
4 mths 127 78 (14) 70.7 (14.6) 0.004†
12 mths 123 82.3 (13.1) 78.6 (17.1) 0.09
24 mths 104 76.7 (15.1) 70.7 (19.1) 0.06
48 mths 84 76.8 (13.1) 72.1 (19.8) 0.49
Mean HHS score, pain (SD)
4 mths 127 39.6 (8.2) 37.2 (9.1) 0.07
12 mths 123 40.7 (8.8) 38.9 (9.0) 0.10
24 mths 106 39.4 (8.8) 36.8 (9.4) 0.04†
48 mths 86 40.8 (6.6) 37.2 (10.1) 0.07
Mean SMFA score, dysfunction (SD)
Preoperative 138 17.9 (13.8) 21.2 (14.3) 0.14
4 mths 125 29.8 (17.5) 39.2 (19.6) 0.007†
12 mths 118 22.3 (16.3) 34.9 (22.2) 0.001†
24 mths 102 26.4 (19.4) 33.2 (21.8) 0.12
48 mths 82 32.4 (25.0) 34.3 (24.3) 0.63
Mean SMFA score, bother (SD)
Preoperative 133 12.7 (14) 12.5 (11.3) 0.55
4 mths 117 26.9 (19.4) 32,2 (19.9) 0.11
12 mths 116 18.6 (16.8) 29 (21.1) 0.007†
24 mths 102 18.7(16.0) 28.3 (21.3) 0.027†
48 mths 81 25.2 (22.6) 28.1(22.0) 0.57
*Student’s t-test
†Statistically significant

Table IV. Radiological assessment; the data are presented as the numbers according
to available radiographs at the different follow-ups

Assessment Cemented stem Cementless stem

Brooker, 24 mths*
None 9/48 8/46
Islands 19/48 21/46
Spurrs > 1 cm apart 15/48 13/46
Spurrs < 1 cm apart 4/48 3/46
Ankylosis 1/48 1/46
Brooker, 48 mths*
None 6/37 8/37
Islands 15/37 16/37
Spurrs > 1 cm apart 13/37 12/37
Spurrs < 1 cm apart 3/37 1/37
Baker, 24 mths†
None 15/24 15/23
Joint space narrowing 9/24 8/23
Joint space disappeared 1/24 0/23
Baker, 48 mths†
None 10/17 10/17
Joint space narrowing 6/17 6/17
Joint space disappeared 0/17 1/17
Protrusio 1/17 0/17
*For all arthroplasty types
†For hemiarthroplasty patients only

Radiological assessment. Subsidence of the stem by > 5 mm Discussion

was seen in 8.5% (4/47) of the cemented group and in 6.4%
(3/47) of the cementless group at the 24-month follow-up
(p = 0.7); and in 14% (5/37) of the cemented group and 8.3%
(3/36) of the cementless group at 48 months (p = 0.5). No
component showed signs of loosening at any time. The
frequency of HO formation and acetabular erosion were
similar in the two groups (Table IV).
The main finding in this study was that the differences in
function one year postoperatively in patients with a fracture of
the hip treated with a cemented or cementless stem disappeared
with the passage of time. Good functional outcomes followed
the use of both forms of fixation, two years postoperatively,
with few adverse events and similar mortality. The function,
assessed by the HHS, peaked 12 months postoperatively and

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1092 B. BARENIUS, C. INNGUL, Z. ALAGIC, A. ENOCSON
subsequently decreased although the pain subscore remained
similar in both groups. This finding differs from that of Langslet
et al,18 who reported better HHSs after five years for patients
with a cementless stem. The mean HHS in our patients was
similar to theirs at one and four years postoperatively for the
cemented group, but there was a large difference for the
cementless group. However, in their series, less than 50% of the
patients who were available one year postoperatively were
available five years postoperatively. Only 34% of the patients
remained in the cementless group, compared with 58% in our
series. We noted a trend of decreasing HRQoL, EQ-5D and an
increasingly impaired SMFA in the cemented group over time.
We interpret this as reflecting older age and decreasing general
health rather than an effect of the different methods of fixation
of the stem. It could also be an effect of the mixed population of
patients undergoing THA and HA, as the decrease in the EQ-5D
seemed to be more pronounced in the cemented HA subgroup.
We noted five postoperative periprosthetic fractures, two in
the cemented group (3%) and five in the cementless group
(6.8%) between one and four years postoperatively. This
difference was not statistically significant (p = 0.4). In a
randomized trial comparing 112 cemented bipolar arthroplasties
with 108 cementless bipolar arthroplasties, Langslet et al18
found 7.4% periprosthetic fractures in the cementless group,
compared with 1% in the cemented group after five years.
However, only three out of the eight fractures in the cementless
group occurred after the one-year follow-up. Sköldenberg et al34
reported six (12%) fractures, all after two years, in a series of
patients with a fracture of the femoral neck treated with a
cementless THA.
In summary, few patients in these studies have follow-up of
up to five years and the differences in frequency of
periprosthetic fractures between the types of fixation after 4
years could be explained by chance. It seems reasonable to
assume that the long-term risk of a periprosthetic fracture in
these patients will be more affected by the risk of falling again
rather than by the type of fixation of the stem. The long-term
risk of developing a complication with a cementless stem might
be acceptable but combined with the risk of an early
complication the picture is different. There was a higher
frequency of intraoperative complications in the cementless
group in the initial report of this study,11 leading to a higher total
risk of a complication for patients treated in this way. This
reasoning is in line with the current literature. In a recent meta-
analysis, Veldman et al35 reported that the risk of a complication
was a factor favouring the use of a cemented stem. Chammut et
al9 stopped their randomized controlled trial due to a high rate of
early complications in the cementless group, and Rogmark et
al14 found a hazard ratio for reoperation of 3.6 due to
periprosthetic fracture after the use of a cementless compared
with a cemented stem in their register study.
Few patients with either form of fixation require further
surgery up to four years postoperatively. In the early report of
this study, one patient underwent surgery due to instability and
one due to infection, during the first postoperative year.11 No
patient has subsequently required further surgery for these
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indications. The mortality in this study was similar to other
studies.9,17,18,36 The size of the study makes further analyses of
mortality uncertain, but there seemed to be no differences
between the groups. There are reports from large cohorts that a
higher mortality one day postoperatively follows the use of a
cemented stem. Costain et al37 found a statistically significant
difference, with a mortality one day postoperatively of 0.5% in
a cementless group and 0.8% in a cemented group (p < 0.001).
The risk of death was, however, reversed after one week and
remained higher in the cementless group, with mortality of 21%
after one year in the cemented group and 30% in the cementless
group (p < 0.001). Our interpretation of these findings is that the
risk of cement syndrome leading to an increased risk of death is
not a valid argument for choosing a cementless stem, the 0.3%
lower risk the first day is not comparable with the higher
mortality from one week adding up to 9% higher mortality after
1 year in the cementless stem group.
The main strengths of the study are the relatively long follow-
up and the well-structured study protocol. The study, however,
has limitations. The power analysis was performed to compare
the one-year results and the conclusions are weakened by the
subsequent loss to follow-up and selection bias in relation to the
patients that were available at the final follow-up. Some of the
patients who were alive and declined to take part did so because
of comorbidities which were not related to the fracture, such as
dementia or general health issues due to age. The study was
originally designed as two separate studies and the mixed cohort
of patients undergoing THA and HA could be a confounding
factor, especially regarding function and HRQoL. However, the
stems used were the same, and the same method of
randomization was used for the THA and HA groups. The
proportion of patients treated with THA and HA in the groups
remained similar over time. We deem the effect from the mixed
groups to have a very minor impact on the results of the stems
because there were similar amounts of drop outs in all groups.
In conclusion, we confirmed that patients with a displaced
femoral neck fracture treated with an arthroplasty using a
cemented or a cementless stem had good function and few
complications up to four years postoperatively. However, due to
the poor short-term functional results in the cementless group,
the findings do not support their routine use in the treatment of
these elderly patients.
Take home message:
-This randomized controlled trial reports similar results four
years after a displaced femoral neck fracture treated with a
cemented or cementless arthroplasty, but due to the earlier
published one year results with higher complication frequencies in the
cementless stem group, the cemented stem solution is deemed a safer
choice for this patient group.
- The clinical relevance of the study is that orthopaedic surgeons treating
patients with displaced femoral neck fractures should be aware of the
early complications in their treatment choice because the long-term
results for the survivors are good regardless of fixation.
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Author contributions:
B. Barenius: Designing and planning the study, Collecting and analyzing the
data, Writing the manuscript.
C. Inngul: Designing and planning the study, Collecting and analyzing the
data, Writing the manuscript.
Z. Alagic: Designing and planning the study, Analyzing the radiographs. Writ-
ing the manuscript.
A. Enocson: Designing and planning the study, Collecting and analyzing the
data, Writing the manuscript.
Funding statement:
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
Acknowledgements:
The authors wish to thank Sari Ponzer and Richard Blomfeldt, both at Depart-
ment of Orthopaedics and Clinical Science and Education, Karolinska Insti-
tute, Stockholm South Hospital, Stockholm, Sweden, for their valuable
contribution to the study.
To make this study possible the authors also would like to acknowledge the
work by the research nurses Catharina Levander and Elisabeth Skogman, and
the study surgeons Buster Sandgren, Radford Ekholm, Carl-Johan Hedbeck,
Per Hamberg, Rickard Miedel, Ulla Lind, Karl Eriksson, Lasse Lapidus, Anders
Norrman, Richard Blomfeldt, Uffe Hylin, Christian Inngul, Anders Enocson
and Hasse Törnkvist.
This article was primary edited by J. Scott.