A modular hemiarthroplasty has a Metal-on-Metal (MoM) taper-trunnion junction, which may lead to increased wear and Adverse-Reaction-to-Metal-Debris (ARMD). To-date no wear related issues have been described in the elderly and less active that receives a hemiarthroplasty. This study aims to determine in vivo wear (i.e. serum metal ion levels) in hip hemiarthroplasty, and identify factors associated with increased wear.

This is a prospective, IRB approved, single-centre, cohort study of patients that received an uncemented, modular hemiarthroplasty of proven design for the treatment of hip fracture between 2013–2015. All, alive, patients at 12-months post-implantation with AMTS≥6 were invited to participate. Of the 125 eligible patients, 50 accepted the invitation and were reviewed, including clinical/radiological assessment, metal-ion ([Chromium (Cr) and Cobalt (Co)]) measurement and Oxford Hip Score (OHS). Acetabular erosion was graded (0–3: normal-protrusio). Metal ion levels were considered high if ≥7ppb.

The mean OHS was 37 (SD: 10). No acetabular erosion was detected in 21, whilst the remaining had either grade-1 (n=21) or grade-2 (n=8). The median Cr and Co levels were 2.9 (SD:9) and 2.2 (SD:4) respectively. There were 8 cases (16%) with high ion levels. To-date only 2 of them has an ARMD lesion, and none have been revised. Patients with metal ion levels had similar pre-fall mobility, taper- and head- size and OHS to those with low metal ion levels (p=0.2–0.7) However, all hips with high metal ion levels had evidence of acetabular erosion (≥1).

Modular Hip hemiarthroplasties and their taper-trunnion junction are not immune to high wear and ARMD despite being implanted in a less active cohort. Acetabular erosion should alert clinicians, as it is associated with 20× increased-risk of taper wear, presumably due to the increased transmitted torque. Whether the use of modular hemiarthroplasties should remain is debatable.

It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice.

During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for.

Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list.

Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.

Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. We aim to show the Inverness experience.

We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery.

2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture since 1996. 1708 female (77%) and 513 male (23%). Ages ranged from 28 years to 104 years (mean 80). 2180 of this group had their operations in Raigmore with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain.

Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients.

The Austin Moore Prosthesis (AMP) is a recognised treatment option in the management of displaced intracapsular femoral neck fractures in elderly patients. Peri-prosthetic femoral fractures are a potential complication of both cementless and cemented hemiarthroplasty and can occur intra-operatively or at any stage following implant insertion.

Over a two-year period, 244 patients underwent hemiarthroplasty for a displaced intracapsular femoral neck fracture. Seventy patients had an AMP inserted whilst 174 patients were treated using a cemented Thompson stem. All of the AMP’s were inserted by, or under the supervision of an orthopaedic consultant.

Five patients (7%) from the AMP group sustained a periprosthetic femoral fracture. Four required revision surgery. The remaining case was managed non-operatively.

When compared to the cemented Thompson hemiarthroplasties performed over the same time period, despite the operating time being significantly less, the number of periprosthetic femoral fractures was significantly greater with the AMP. Furthermore, the early mortality rate was significantly higher for the AMP group who, were also significantly older and more likely to require postoperative blood transfusion. There was no significant difference in gender or ASA grade between the two groups.

These findings suggest that for displaced intracapsular femoral neck fractures in elderly patients, when hemiarthroplasty is the treatment of choice, a cemented prosthesis is preferable.

Most studies about hemi-arthroplasty of hip have focused on clinical aspects. Design features of various implants of hemi-arthroplasty have not been studied extensively. The aim was to investigate the relationships between radiological variables and possible mode of failure in various hemiarthroplasty implants in intracapsular neck of femur fractures.

A retrospective review of 42 hemi hip arthroplasties, Austin Moore and Thompson prosthesis by Biomet, Medical Product Service (Tipsan) and Smit Medimed (SMPL) used in our hospital. Controversy exists between indication for a particular design in an unselected series of patients once excluding the choice of cementing or uncementing the prosthesis. In monoblock prosthesis not only the head-neck region affects the stability but also the stem fit in proximal femur.

Surgeon preference to technique and approach excluded. Premorbidly all patients were mobilising independently. 5 criteria reviewed. 1) head size of prosthesis 2) neck length 3) prosthesis stem shaft angle 4) stem-cortical distance ratio and 5) shape of the femoral canal as classified by Dorr. Head size compared in AP views of involved hip and normal head size compared with that of prosthesis. A difference <2 mm or >3 mm indicative of incorrect size. Neck length measured by the vertical distance from center of head to superior aspect greater trochanter was zero. A range of +/− 5 mm was acceptable. Neck shaft angle with a difference of >5 degrees was indicative of varus position of the stem. Canals of the proximal femoral categorized as a) stove pipe b) champagne c) fluted varieties radiologically. X-ray magnification corrected. All measurements were done on immediate postoperative radiographs.

Stability of various design features of straight stemmed and curved implants are dependant on the anterior bowing angle and canal ratio of femur to prosthesis. A prospective study with CT from selected shapes of the proximal femoral is being carried out. Inappropriate head size as reported by Thompson or neck length was related to incidence of dislocation resulting in failure. Our findings emphasise importance of careful selection of a particular implant design towards the morphology of the femoral canal.

Following the recommendation of NICE guidelines (CG124) we have recently started using cemented smooth tapered stem hemiarthroplasty as our standard management of intra-capsular neck of femur fractures. Prior to publication of the above guidelines the standard implant utilised was Thompson Hemiarthroplasty prosthesis. The cost implications of this change have not been fully appreciated and the benefit of these changes in ASA grade 3–4 patients has not previously been analysed.

We identified a cohort of 89 patients admitted with displaced intra-capsular neck of femur fracture with an ASA grade 3–4. These underwent hip hemiarthroplaties at our centre over a period of 12 months (before and after guideline implementation). Data regarding in-hospital mortality, dislocation, reoperation and place of discharge were retrospectively collected and analysed.

Our cohort included 46 patients who underwent a Thompsons Hemiarthroplasty, 30 patients who had a cemented smooth tapered stem hemiarthroplasty and 13 patients who had an Austin-moore Hemiarthroplasty.

In-patient mortality rates were highest in the Austin-moore group, followed by the Thompsons group compared to none in the smooth tapered stem group. However, this was not statistically significant. One patient in the Thompsons group and one patient in the smooth tapered group had multiple dislocations and re-operations, compared with none in the Austin-moore group. In terms of percentage of patients who were discharged home from hospital the smooth tapered stem group had a percentage that was more than twice that of the Thompson's which was in turn higher than that found in the Austin-moore group.

In conclusion, our data suggests that in patients with an ASA grade of 3–4 there is no significant benefit from using cemented smooth tapper stems when performing a Hip Hemiarthroplasty compared with a well performed Thompsons and that the cost savings of this is significant. We accept that our current numbers are relatively small and further work is needed.

Background

In Sweden approximately 6000 patients yearly sustain displaced femoral neck fractures. During the last decade there has been a shift towards more arthroplasties at the expense of internal fixation. In 2008 approximately 75% of the dislocated femoral neck fractures in Sweden were treated with arthroplasties. Those patients are typically elderly and frail and the vast majority of them receive hemiarthroplasties. In 2005 a national hemiarthroplasty registration was established as part of the Swedish Hip Arthroplasty Register (SHAR).

One of the most common early complications after hemiarthroplasty is dislocation, with an incidence of 2 to 4%. After dislocation the mortality and morbidity are significantly increased to in excess of 50%.

It has been claimed that a bipolar hemiarthroplasty has a lower risk of dislocation than a unipolar implant. In addition it has been suggested that patients with either Parkinson’s disease or a previous stroke are at increased risk of dislocation. We investigated these claims by performing a comprehensive literature search of articles published in the last 40 years and data obtained from our own hip fracture database.

From the literature review, 133 reports involving 21,872 patients were retrieved. A further 1235 hip fractures treated by hemiarthroplasty were recorded from our database. 791 (3.4%) dislocations were recorded. Dislocation rate for unipolar prosthesis was higher than bipolar prosthesis (3.9% versus 2.5%). Dislocation rate for posterior surgical approach was higher than for anterior approach (5.1% versus 2.4%). Dislocation rate for cemented prosthesis was 3.6% versus 2.3% in un-cemented prosthesis. However, the effect of the type of implant becomes non-significant on adjusting for the use of cement and surgical approach. The incidence of open reduction after dislocation was increased with bipolar implants. Patients with Parkinson’s disease showed a highly statistically significant increase in dislocation rate (8.7% to 3.4%). The dislocation rate with respect to ipsilateral hemiplegia was 1.6%.

This study indicates there is no difference in the dislocation rate between a unipolar and bipolar prosthesis but if a bipolar prosthesis dislocates, there is an increased risk of failure to reduce the prosthesis by closed means. Patients with Parkinson’s disease are at an increased risk of dislocation but this is not the case for those with a hemiplegia. To minimise the risk of dislocation of a hemiarthroplasty, particularly in those patients with Parkinson’s disease, a unipolar hemiarthroplasty inserted via an antero-lateral approach is recommended.

Total Hip Arthroplasty (THA) and Hip Hemiarthroplasties (HA) are successful, cost-effective procedures that improve quality of life. Dislocation is a well recognised complication with a significant health and economic burden. We aim to establish the current management practices across the United Kingdom (UK) for Prosthetic Hip Dislocations (PHD). Our definition of a PHD includes; THA, HA and revision THA. This national study builds on our regional pilot study and records one of the largest datasets of Prosthetic Hip Dislocation management within the UK. A trainee-led collaborative; the North West Orthopaedic Research Collaborative (NWORC). Conducted a retrospective audit, registered as Quality Improvement (QI) projects, collected data from 38 hospital trusts across the UK. Data was collected on patient-related factors, inpatient management, and outpatient follow up of each PHD episode between January and July 2019. Primary outcome measured definitive management, in the form of revision surgery or the consideration for this through a referral pathway. A total of 673 (THA 504, Revision THA 141, HA 28) patients were included with a total of 740 dislocation episodes. Mean age was 75.6 years with female to male ratio 2:1. The majority of PHDs were a result of a low energy mechanism (98.7%) and presented over 6 months post index procedure (80.5%). Over half (53.8%) attended with a first or second time dislocation. Only 29.9% patients received onward revision referral; whereas 70.1% followed diverse management patterns, including local non-arthroplasty and primary arthroplasty surgeon follow-ups. Revision THAs had higher rates of referral for revision (p<0.001) compared to primary THA and HA dislocations. A high number of PHDs present across the UK, with under a third receiving definitive management plans. This variation increases the economical burden to the National Health Service, highlighting the need for national guidance to manage these complex patients

Total Hip Replacements (THR) and Hip Hemiarthroplasties (HA) are both successful and common orthopaedic procedures. Dislocation is a well-recognised complication carrying significant morbidity and, in some cases, increased mortality risks. We define prosthetic hip dislocations (PHDs) to include both THRs and HAs. Prosthetic Hip Dislocations (PHDs) are a common acute admission yet there are no published guidelines or consensus on management following reduction. A retrospective audit was undertaken by the North West Orthopaedic Research Collaborative (NWORC) between January 2019 and July 2019. A questionnaire was used to capture the management of each dislocation episode presenting to 11 Hospital trusts. The study was registered as a Quality Improvement (QI) project at each site. Data regarding the surgical management physiotherapy input, ongoing care and further management plans were recorded. A total of 183 patients with 229 dislocations were submitted for initial analysis (171 THRs, 10 HAs, 2 PFRs). Female to male ratio was 2:1 with mean age of 76.7 years. Average time to first dislocation was 8.1 years. 61.1% were first or second time dislocators and 38.9% presented with 3 or more dislocations. Initial reductions were predominantly attempted in theatre (96.5%, n=221) with only 3.5% (n=8) attempted in the emergency department. In theatre 89% (n=201) were reduced closed. There was no plan for revision surgery in 70.6% cases with no difference seen between patients with >=3 dislocations and <=2 dislocations. Of the patients with a revision plan, 71% of these were performed or planned locally. The high number of patients with 3 or more dislocations and the lack of plans for definitive interventions in the majority of cases highlights the significant variation in the management of this complex group of patients. This variation in the quality of care increases the burden on the National Health Service through repeat hospital episodes. We aim to roll out this study nationally to assess regional variations and ultimately make the case for national guidance on the management of prosthetic hip dislocations

Purpose of the study: To ascertain, the Post-operative Joint Infection rates in the Department during 2004. Methods used and the results: Details of 607 patients were collected. Females were 379(62%) whereas males were 228(38%). Less than 65 years were 133(22%), between 66 and 80 years were 319(53%) and above 80s figure was 155(26%). Total of 197 Primary Hip Arthroplasties (THR) and 190 Knee Arthroplasties (TKR) had been performed. Hip Hemiarthroplasties totalled 137. All the demographic indicators were looked in detail for gender and age range distribution. Revision THRs were 66 whereas 17 were Revision TKRs. For the purpose of this study, the Revision Arthroplasties were excluded. Amongst Total Joint Arthroplasties, though 10 patients out of 387 had provided positive results for STAA (Staph. Aureus) from swab specimens, none of the patients developed deep infection. But out of 8, who showed MRSA growth from wound swabs, one patient developed deep infection and needed conversion to Girdlestone procedure. Thus the positive results for wound specimens were 18(4.65%), while the re-operation rate was 1(0.26%). Conclusion: It is interesting to note that MRSA was prevalent in above 80s while STAA was more common in under 80s. Majority of MRSA positive results were after 30 days while that for the STAA it was before 30 days post-operatively. Of the 18 ‘infected’ cases; Consultants and SAS surgeons had performed 9 cases each. Amongst 137 Hip Hemiarthroplasties, 25 showed positive growths, 7 for STAA and 18 for MRSA. None needed re-operation. Interesting revelations on misconceptions are revealed!

Bone and joint infections of the lower limbs cause significant morbidity for patients. Infection is a devastating complication for prosthetic joint replacements. In this large case series from a single centre in the NE of England, we present our experience of using antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 for local elution of antibiotics at the site of infection. At our centre, from August 2012 to Jan 2015, antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 was used for local elution of antibiotics in 45 patients with lower limb bone or joint infections. Tailored plans were made by Orthopedic surgeon and Microbiologist MDTs based on bacteria and sensitivities. Cases included 20 THR, 13 TKR, 5 Hemiarthroplasties, 4 tibial nonunions, 1 infected femoral plate and 2 paediatric osteomyelitis. Organisms isolated – Coagulase negative Staphs, Staph aureus, MRSA, E coli, Enterococcus, Enterobacter cloacae, Serratia and 1 Salmonella typhimurium!!. In our cases, a combination of Vancomycin and Gentamicin was added to Stimulan beads following manufacturer's mixing guide. In 2 cases, we added Ceftazidime to the beads and Daptomycin in 1 case. In bone infections, surgical debridement and systemic antibiotics were also needed. All arthroplasty infections underwent explantation with addition of antibiotic impregnated beads either at single stage or both stages of 2 stage revisions and systemic antibiotics. Follow up (ranging 9months to 2 years) indicates no failure so far. The beads caused no excessive wound drainage. There was no need to remove beads as they dissolve. In the cases where a staged revision was performed, the beads were inserted at first stage and there was microbiological clearance of infection at 2nd stage. Our series includes some experince in paediatric cases too. As far as we are aware, this is the largest series in the UK from a single centre reporting experience with Stimulan in infected bone and joints of the lower limbs. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with carefully selected antibiotics, works as an effective adjunct to current treatments and offers flexibility with choice of antiobiotics that can be added locally. Acknowledgements. Biocomposites UK for supporting attendance at EBJIS. Authors control ownership of all data and analysis

Introduction and Aims: Nine countries have established national joint replacement registries. The first population-based national registry, the Swedish Knee Registry, was established in 1975 with the most recent, the UK National Joint Registry (UK NJR), beginning in 2003. We identify commonalities and differences in the structure, function and methods of reporting among these national registries. Method: Data was collected from the annual reports of the various registries, published literature and personal contact with registry coordinators and directors. Results: Commonalities include registry ownership, source of funding, procedure types collected, method of data collection and validation of data. Most registries are owned by the national Orthopaedic Association or a government agency. The most common source of funding is government; membership fees and a mandated implant levy are also used. Most national registries collect total hip and knee replacements, primaries and revisions. Hemiarthroplasties are not commonly collected, though some registries collect additional joints (including shoulder, elbow, wrist, finger, ankle and toe). The most common method of data collection is paper-based, usually from theatre, with subsequent data entry at the registry. Electronic data collection is used to supplement the paper-based system in some countries, while the Swedish Hip Registry and the UK NJR utilise a web application for the submission of data. Most registries attempt to validate their data against hospital inpatient data held by government. Differences include reporting of rates, cost per registration and definitions. Failures of primary implants may be reported as cumulative proportions, true incidence rates or survival probabilities. This leads to difficulties in comparison of data among the national registries. The cost of registering a procedure varies up to five-fold across countries. Conclusion: There are obvious opportunities for collaboration between national joint replacement registries, however some issues need to be addressed. These include definitions of what is collected, for example hemiarthroplasties, and methods of analysis and reporting, especially revision rates

Aims

The aim of this meta-analysis is to assess the association between exchange of modular parts in debridement, antibiotics, and implant retention (DAIR) procedure and outcomes for hip and knee periprosthetic joint infection (PJI).