Aims. The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. Methods. A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m. 2. are considered “high risk” by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode. Results. In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were “high risk”. Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202. Conclusion. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units. Cite this article: Bone Jt Open 2023;4(8):559–566

The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC. Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result. All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process. Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%. Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441. Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773). Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement. This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases

Aims. The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. Methods. The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds. Results. The expert group achieved strong consensus in 32 out of 36 factors following the Delphi process. The RHCC used the existing Paprosky (acetabulum and femur), Unified Classification System, and American Society of Anesthesiologists (ASA) classification systems. Patients with ASA grade III/IV are recognized with a qualifier of an asterisk added to the final classification. The classification has good intraobserver and interobserver reliability with Kappa values of 0.88 to 0.92 and 0.77 to 0.85, respectively. Conclusion. The RHCC has been developed through a modified Delphi technique. RHCC will provide a framework to allow discussion of complex cases as part of a local or regional hip revision MDT. We believe that adoption of the RHCC will provide a comprehensive and reproducible method to describe each patient’s case with regard to surgical complexity, in addition to medical comorbidities that may influence their management. Cite this article: Bone Jt Open 2022;3(5):423–431

Aims. The risk of mechanical failure of modular revision hip stems is frequently mentioned in the literature, but little is currently known about the actual clinical failure rates of this type of prosthesis. The current retrospective long-term analysis examines the distal and modular failure patterns of the Prevision hip stem from 18 years of clinical use. A design improvement of the modular taper was introduced in 2008, and the data could also be used to compare the original and the current design of the modular connection. Methods. We performed an analysis of the Prevision modular hip stem using the manufacturer’s vigilance database and investigated different mechanical failure patterns of the hip stem from January 2004 to December 2022. Results. Two mechanical failure patterns were identified: fractures in the area of the distal fluted profile (distal stem fracture) and failure of the modular taper (modular fracture). A failure rate of 0.07% was observed for distal stem fracture, and modular fracture rates of 1.74% for the original and 0.013% for the current taper design. Conclusion. A low risk of mechanical failure for both fracture types was observed compared to other known complications in revision hip arthroplasty. In addition, the data show that a design change did significantly reduce the risk of a modular fracture. Cite this article: Bone Joint J 2024;106-B(2):151–157

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost. This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations. The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age. The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system

The purpose of this study was to determine long-term survival free from all-cause revision and stem-related failure, as well as radiographic and functional outcomes of the ZMR stem in revision THA. We retrospectively identified all patients in our institutional database who underwent revision THA using the ZMR Revision Hip system from the year 2000 to 2007 (minimum two-year follow-up). Of the 112 ZMR hips (110 patients) identified, a total of 106 hips (104 patients) met inclusion criteria. The mean study follow-up 13.9 years (range 2–22). Indications for index ZMR revision included aseptic loosening (72.1%), periprosthetic joint infection (17.3%), periprosthetic fracture (9.6%), and stem fracture (1.0%). Kaplan-Meier analysis was used to determine the all-cause and stem-related failure revision-free survival. Validated patient reported outcomes were collected and available radiographs were reviewed to determine implant stability. A total of 17 hips (16.0%) underwent a re-revision of any component. The indications for re-revision were stem failure (35.3%), infection (29.4%), instability (29.4%), and aseptic loosening of the acetabular component (5.9%). The five- and 15-year all-cause survivorship was 89.5% (95% CI 86.5–92.5) and 83.0% (95% CI 79.2–86.8), respectively. There were six re-revisions for stem failure (5.7%); five for stem fracture and one for aseptic loosening. The average time to stem failure was 4.6 years (range 1.3–8.2). The five- and 15-year survivorship free from stem-related failure was 97.2% (95% CI 95.6–98.8) and 93.9% (95% CI 91.5–96.3), respectively. At final follow-up the mean Oxford hip score was 36.9 and all surviving ZMR stems were well fixed on radiographs. Femoral revision with the ZMR stem offers satisfactory long-term survivorship and promising clinical outcomes. Although uncommon, stem fracture was the most common reason for stem-related failure

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes. Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection. The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window. Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure. On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig). This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry

Aims

The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.

Fracture of contemporary femoral stems is a rare occurrence. Earlier THR stems failed due to design issues or post manufacturing heat treatments that weakened the core metal. Our group identified and analyzed 4 contemporary fractured femoral stems after revision surgery in which electrochemical welds contributed to the failure.

All four stems were proximally porous coated titanium alloy components. All failures occurred in the neck region post revision surgery in an acetabular cup exchange. All were men and obese. The fractures occurred at an average of 3.6 years post THR redo (range, 1.0–6.5 years) and 8.3 years post index surgery (range, 5.5–12.0 years). To demonstrate the effect of electrocautery on retained femoral stems following revision surgery, we applied intermittent electrosurgical currents at three intensities (30, 60, 90 watts) to the polished neck surface of a titanium alloy stem under dry conditions.

At all power settings, visible discoloration and damage to the polished neck surface was observed. The localized patterns and altered metal surface features exhibited were like the electrosurgically-induced damage priorly reported.

The neck regions of all components studied displayed extensive mechanical and/or electrocautery damage in the area of fracture initiation. The use of mechanical instruments and electrocautery was documented to remove tissues in all 4 cases.

The combination of mechanical and electrocautery damage to the femoral neck and stem served as an initiation point and stress riser for subsequent fractures. The electrocautery and mechanical damage across the fracture site observed occurred iatrogenically during revision surgery. The notch effect, particularly in titanium alloys, due to mechanical and/or electrocautery damage, further reduced the fatigue strength at the fractured femoral necks. While electrocautery and mechanical dissection is often required during revision THA, these failures highlight the need for caution during this step of the procedure in cases where the femoral stem is retained.

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region. Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results. Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year. Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?

Introduction

A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery.

Allogenic blood is a finite resource, with associated risks. Previous studies have shown intra-operative cell salvage (ICS) can reduce allogenic transfusion rates in orthopaedic surgery. However, recent concerns regarding the efficacy and cost-effectiveness of ICS mean we must continually re-assess its usefulness in current practice. This study was carried out to review the use of ICS, to establish if its use has led to a reduction in patient exposure to post-op allogenic transfusion. All orthopaedic patients who underwent ICS and re-infusion between 2008–2010 in the Southern General Hospital (SGH) were audited. The Haemoglobin (Hb) drop, volume of blood re-infused and post-op allogenic transfusion rates were recorded. The revision hip group was compared to a similar SGH cohort, who underwent surgery by the same surgeons between 2006–2008, and a pre-2005 control group. The Cell Saver (Haemonetics) machine was used. The proportion of patients who received a post-op allogenic transfusion fell by 55% in the 2008–2010 ICS cohort compared with the control, and by 40% compared with the previous ICS study group. In both instances, this was accompanied by a statistically significant (p<0.001) reduction in mean number of units transfused per patient. ICS has been shown to be effective in reducing rates and volume of post-op allogenic transfusion in patients undergoing revision hip surgery at the SGH. ICS has been used with increasing efficiency over time

Introduction: Revision hip surgery is likely to become more frequent with the continued use of cemented primary hip prostheses. Primitive stem cells from bone marrow become osteocytes in the presence of hydroxyapatite ceramic (HAC). Consequently there is osseointegration of an HAC surface in bleeding cancellous bone/marrow. However, damaged bone in the revision situation does not provide the necessary stem cells for osseointegration. Revision surgery using standard length (150mm) HA coated stems is not always satisfactory. Using a 200 mm stem will extend the operating field into fresh, undamaged cancellous bone and marrow. Method: Since 1988 more than 2600 HAC hips have been implanted for primary and revision hip cases. This includes 148 revisions. The continued use of primary HAC hips has reduced the necessity for revision hip surgery. There is a dwindling population of cemented, loosening hips requiring revision. Patients are assessed radiologically and using the Harris Hip Score (HHS) pre. and post-operatively on an annual basis. Results: Since 1991 the longer 200mm stems have been used in 73 cases. The results have been rewarding. The system works with improved HHS. Defects from debris disease fill in and stems are seen to bond to the host bone particularly at the tip. There have been no prosthetic fractures. Only one case has needed re-revision when a stem remained un-bonded in the presence of a transverse femoral fracture. Two other stems are probably not bonded. This represents 4% failure. Discussion: HA bonding is a successful system of fixation in primary hip arthroplasty. Using a 200mm stem in revision cases allows virgin bone marrow to provide the necessary stem cells for fixation. These longer HA coated stems should be used in revision surgery

Significant proximal femoral bone deficiency in revision hip surgery poses a considerable challenge, especially as revision hip surgery is increasing in prevalence. Many femoral prosthetic devices, which compensate for this bone loss, are available to surgeons but ideally one wants to restore viable proximal bone stock. The Oxford Universal Hip (OUH) has been designed and modified with these challenges in mind. This is atrimodular, non-locking device that allows for some rotation and subsidence in the cement. Load transfer occurs at the proximal wedge, thus avoiding proximal stress shielding. The OUH has been used extensively in both primary and revision hip surgery and is particularly useful when used in conjunction with proximal impaction bone grafting. The main aim of this study was to determine the clinical outcome of the patients. The viability and survivorship of the impacted bone graft was assessed in order to give some indication of adequate perfusion of the incorporated bone grafting. Between 1999 and 2002 the OUH, in combination with proximal impaction bone grafting, was implanted in 72 hip revisions in 69 patients. All patients were clinically evaluated using the Oxford Hip score. Histological samples of impacted bone grafting were analysed by a pathologist 2 years after implantation to assess viability and perfusion of the impacted bone graft. The Oxford Hip Score improved from a pre-operative to a post-operative score of 45 (26–58) to 24.3 (12–43) respectively (p< 0.001). The mean follow up time was 32.7 months and in that time there were no re-revisions for aseptic loosening. Histology demonstrated viable bone stock in the proximal femur where bone grafting had been impacted 2 years previously. The OUH is a versatile hip prosthesis for use in revision hip arthroplasty and is especially well suited to proximal impaction bone grafting where it is possible to restore viable bone stock

Background. Hip arthroscopy is a rapidly growing, evolving area within arthroscopic Orthopaedic Surgery, with annual rates increasing as much as 25-fold each year. Despite improvements in equipment and training, it remains a challenging procedure. Rates of revision surgery have been reported as 6.3% to 16.9%. Objectives. The primary objective was to determine the success of joint preservation after hip arthroscopy. The secondary objective was to determine whether patient characteristics or PROM functional score trends could predict revision hip arthroscopy or Total Hip Arthroplasty (THA). Study Design & Methods. We reviewed 1363 hip arthroscopies performed from January 2010 to December 2016 by a single high-volume surgeon at a single institution. Data was prospectively collected and retrospectively reviewed with a minimum 2-year follow-up. Functional outcomes were assessed with the International Hip Outcome Tool (IHOT-33). Hip arthroscopy failures were defined as Total Hip Arthroplasty or revision hip arthroscopy after index hip arthroscopy. Results. There were751 females and 612 males with an average age of 34.63 years (19 – 58 years). There were 199 cases (14.6%) of labrum repairs only, 286 (20.9%) cam and labrum repairs, 319 (23.4%) cam and pincer surgeries and 193 (14.1%) cam only surgeries. All pre-operative IHOT-33 patient-reported outcomes scores (27.42 ± 6.2) improved significantly at the 6 week-, 3 month- and 6-month follow-up visits (p<0.05). The best improvements were seen in symptoms and functional improvements (IHOT-SFL) (p<0.05) while the poorest amelioration of job-related concerns (IHOT-JRC) existed at all time points (p<0.05). There were 223 failures, 131 patients (9.61%) underwent revision hip arthroscopy and 92 required THA (6.75%) at 18.45 months ± 7.34 months. The 2-year survival rate was 89.2%. The THA conversion rate was 8.4% for patients > 50 years old and 3.72% for patients < 50 years old. Age (>50 years) and female sex were associated with increased risk of conversion to THA (p<0.05) while young (<25 years old) and female patients were most likely to undergo hip revision arthroscopy. Surgery involving repair of the labrum only are more likely to result in revision arthroscopy surgery and THA (70.7% at 10.6 years). CAM & pincer surgery have best longevity (90.9% at 10.6 years). Conclusions. Joint preservation and no subsequent surgery at 10.6 years is 83.64%. This study showed that predictors of revision hip arthroscopy or THA included poor pre-morbid functional score, female gender, age > 45, sudden functional score decrease at 3 months follow-up and cases in which only the labrum is surgically repaired

Aims. The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Methods. Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups. Results. Data were analyzed from 568 patients, recruited in 38 UK secondary care sites between October 2017 and October 2018 (43.5% male; mean (SD) age 71.86 years (9.93); 305 hips, 263 knees). No significant inclusion differences were identified between the two groups. For hip revision, time to revision > ten years (odds ratio (OR) 3.804, 95% confidence interval (CI) (1.353 to 10.694), p = 0.011), periprosthetic fracture (OR 20.309, 95% CI (4.574 to 90.179), p < 0.001), and dislocation (OR 12.953, 95% CI (4.014 to 41.794), p < 0.001), were associated with unplanned revision. For knee, there were no associations with route to revision. Revision after ten years was more likely for those who were younger at primary surgery, regardless of route to revision. No significant differences in cost outcomes, length of surgery time, and access to a health professional in the year prior to revision were found between the two groups. When periprosthetic fractures, dislocations, and infections were excluded, healthcare use was significantly higher in the unplanned revision group. Conclusion. Differences between characteristics for patients presenting for planned and unplanned revision are minimal. Although there was greater healthcare use in those having unplanned revision, it appears unlikely that routine orthopaedic review would have detected many of these issues. It may be safe to disinvest in standard follow-up provided there is rapid access to orthopaedic review. Cite this article: Bone Joint J 2022;104-B(1):59–67

Introduction: In a climate of tightening budgets and rising cost the pressure on those performing complex and expensive surgery is ever increasing. Patients requiring revision hip surgery are a particular burden on such limited resources. Hospital trusts are dependent upon adequate remuneration for such complex procedures, a process reliant on accurate coding. Methods: We performed a retrospective audit of our coding for revision hip surgery. This highlighted significant shortfalls in the coding process. We implemented necessary changes prior to a further prospective audit. Results: The primary procedure was correctly coded in all our cases throughout, creating a standard tariff (mean £6,897). However certain procedures enable an additional tariff uplift of up to 70%. Yet these additional procedures (performed in 81% of our procedures) had not been coded; loosing these additional tariff uplifts of 70%. We involved and educated our coding staff, creating a ‘tick box’ sticker to be placed on every revision hip operation-record and completed by the operating surgeon. Our subsequent tariff uplifts for these procedures have been significant. Discussion: Joint replacement surgery is being performed in an ever younger and more active population. Patients are increasingly likely to outlive their prosthesis and peri-prosthetic fracture rates are set to continue rising. In the modern NHS, surgeons must have a good understanding of complex tariffs. Coding staff are a notoriously poorly paid and undervalued component of any Hospital Trust, and invariably lack the surgical experience to interpret complex procedures. Trusts must take measures to ensure such large tariff uplifts are not missed for complex procedures. We explain the tariff process and discuss how improvements can easily be achieved by individual trusts

Aim. To evaluate the costs of performing revision hip and knee surgery at a District General Hospital. Methods. A retrospective review of all revision hip and knee surgery between October 2004 and October 2006 was performed. Information was obtained from the notes and theatre log books. Each case was fully costed. The breakdown costs included implant choice, theatre time, length of stay, allograft, blood products and post-operative physiotherapy/OT. The costs were obtained from the hospital financial department and theatre invoices. Payment to the hospital is based on a specific tariff which in turn is determined by coding each patient episode. We individually coded every case, using the OPCS 4.3 coding system, and applied the appropriate tariff. The tariffs that the financial department had applied to each case were also available. A comparison was made between actual costs incurred, the expected reimbursement (from our study coding) and the actual reimbursement received (from finance department). Results. 167 revision procedures were performed (108 hips and 59 knees). The total incurred cost of revision hip surgery was £930,156 (mean £8,613 per case). The expected total reimbursement according to our coding was £938,325 (mean £8,688). The total reimbursement actually received was £806,836 (mean £7,471). The total incurred cost of revision knee surgery was £493,357 (mean £8,362). The expected total reimbursement according to our coding was £499,042 (mean £8,458). The total reimbursement was £419,157 (mean £7,104). Conclusions. Inadequate coding results in reduced income. If strict coding practices are adhered to then performing revision hip and knee surgery should be financially viable at a district general hospital

Introduction. Revision hip arthroplasty with massive proximal femoral bone loss remains challenging. Whilst several surgical techniques have been described, few have reported long term supporting data. A proximal femoral allograft (PFA) may be used to reconstitute bone stock in the multiply revised femur with segmental bone loss of greater than 8 cm. This study reports the outcome of largest case series of PFA used in revision hip arthroplasty. Methods. Data was prospectively collected from a consecutive series of 69 revision hip cases incorporating PFA and retrospective analyzed. Allografts of greater than 8 cm in length (average 14cm) implanted to replace deficient bone stock during revision hip surgery between 1984 and 2000 were included. The average age at surgery was 56 years (range 32–84) with a minimum follow up of 10 years and a mean of 15.8 years (range). Results. From the original cohort four patients had died with the original PFA, 21 (30.4%) patients required further surgery with 14 (20.3%) of these needing revisions of the femoral component. The mean time to femoral revision was 9.5 years and Kaplan-Meier survivorship analysis demonstrates a 79.9% PFA survivorship at 20 years. Discussion. Proximal femoral allograft affords long lasting reconstruction of the femoral component in revision hip surgery. We advocate PFA as an attractive option in the reconstruction of the hip in the presence of significant segmental bone loss in younger patients

Postoperative dislocations are known to be a big problem in revision surgery. In literature dislocation rates vary from 4.8% to 33% after previous surgery. In revision surgery, impingement of the implant components, the capsular and soft tissue release, muscular weakness and greater trochanter problems can give additional instability. The reason for revision is important, where instability, infection and tumour cases will lead to a higher percentage of dislocations. The use of big metal heads on polyethylene should be avoided because of the higher volumetric wear. With the new developments of metal-on-metal hip resurfacing and the production of big modular metal heads, the metal-on-metal bearing should guarantee a low-wear result without osteolysis. Between November 2000 and December 2003 45 patients requiring a revision were treated with a Birmingham Hip Resurfacing cup (MMT, UK) and a big metal-on-metal modular head. All surgery was done with a posterolateral approach. Cup sizes range from 44 to 66 mm, head sizes range from 38 to 58 mm. The head sizes most often used were 58 mm, 54 mm and 50 mm. All patients were prospective followed using the Orthowave software (CRDA France). In this series of 45 revisions (mean age 56.17) with large modular heads we encountered 2 dislocations, which give us a dislocation rate of 4.4%. One of these dislocations became recurrent and was revised to a full-constrained acetabular component. Our own dislocation rate in revision hip surgery is 13% (21/159) in the anterolateral approach. Dislocations using the posterolateral approach increased this percentage to 14.8% (21/141). Taking in account that 31% of the causes of revision were infection and recurrent dislocation, this trial demonstrates that large diameter ball heads give beside a better range of movement also a statistically proven reduction in the dislocation rate in revision hip surgery