Objectives. The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?. Methods. We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. Results. We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. Conclusions. Further observational research should be conducted to define the population of interest before future interventional studies are performed. Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1

Aim

This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Aims. Cemented hemiarthroplasty is an effective form of treatment for most patients with an intracapsular fracture of the hip. However, it remains unclear whether there are subgroups of patients who may benefit from the alternative operation of a modern uncemented hemiarthroplasty – the aim of this study was to investigate this issue. Knowledge about the heterogeneity of treatment effects is important for surgeons in order to target operations towards specific subgroups who would benefit the most. Methods. We used causal forest analysis to compare subgroup- and individual-level treatment effects between cemented and modern uncemented hemiarthroplasty in patients aged > 60 years with an intracapsular fracture of the hip, using data from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized clinical trial. EuroQol five-dimension index scores were used to measure health-related quality of life at one, four, and 12 months postoperatively. Results. Our analysis revealed a complex landscape of responses to the use of a cemented hemiarthroplasty in the 12 months after surgery. There was heterogeneity of effects with regard to baseline characteristics, including age, pre-injury health status, and lifestyle factors such as alcohol consumption. This heterogeneity was greater at the one-month mark than at subsequent follow-up timepoints, with particular regard to subgroups based on age. However, for all subgroups, the effect estimates for quality of life lay within the confidence intervals derived from the analysis of all patients. Conclusion. The use of a cemented hemiarthroplasty is expected to increase health-related quality of life compared with modern uncemented hemiarthroplasty for all subgroups of patients aged > 60 years with a displaced intracapsular fracture of the hip. Cite this article: Bone Joint J 2024;106-B(7):656–661

The SPAIRE technique (Saving Piriformis And Internus, Repair Externus) was first described in 2016 and an approach to the hip in the interval between the inferior gemellus and quadratus femoris can be used for both hemi- and total hip arthroplasty. The HemiSPAIRE technique in hip hemiarthroplasty for displaced intracapsular fractures has been compared with the standard lateral approach (advocated by NICE) in a pragmatic, superiority, multicentre, randomised controlled trial into postoperative mobility and function. This NIHR funded study was recruited between November 2019 and April 2022 and the results are reported in this presentation. The author has used the SPAIRE technique in 1026 routine primary total hip replacements since February 2016. The technique is described along with results from NJR data. SPAIRE is most challenging in patients with small anatomy, reduced offset, with an external rotation deformity. Particularly in these, but in all cases, MAKO robotic assistance facilitates accurate implantation of prostheses and precise recreation of biomechanics. The MAKO robot has been used in all cases since 2018 and SPAIRE/MAKO is now the standard of care in the author's practice. To evaluate whether robotic-assisted tendon-sparing posterior approaches (piriformis sparing and SPAIRE), improve patient outcomes in total hip arthroplasty compared with a robotic-assisted standard posterior approach, the NIHR Efficacy and Mechanism Evaluation Programme has recently funded the HIPSTER trial (HIP Surgical Techniques to Enhance Rehabilitation). This is a single-centre, double-blinded, parallel three-arm, randomised, controlled, superiority trial; recruitment is in progress. The greatest value of robotic assistance may be when it is used in combination with tendon-sparing surgery. Data is being gathered to evaluate whether the SPAIRE/MAKO technique confers benefits with regard the speed of post-op mobilisation as well as accelerated return to unrestricted function

Introduction. The National Institute for Health and Care Excellence (NICE) currently recommends the use of total hip replacement (THR) for displaced intracapsular hip fractures in cognitively competent patients and who were independently mobile with the maximum use of one stick prior to the injury. Method. We conducted a prospective cross sectional study of the management of hip fractures within a defined geographic region in the North East of England to assess current practice and variation in provision of THR for displaced intracapsular hip fracture. Results. A total of 879 patients with hip fracture, admitted to eight acute trauma units were included in this study. 169 of 462 patients with displaced intracapsular hip fractures fulfilled the NICE criteria for THR. THR was performed for only 49 of the eligible patients (29%). There was significant variation in THR provision between the eight units (0% THR usage to 50% usage) (p<0.001). In the patients with a displaced intracapsular fracture, there were statistically significant differences in the age, ASA grade, AMTS and pre-injury walking ability between patients who underwent fixation, THR or hemiarthroplasty (all p≤0.05). There was an increased chance of undergoing THR if a patient was 77 years (the median age for the THR eligible cohort) or younger compared to older than 77 years (RR=7.9, 95%CI 2.8–22.0, p<0.001) and if the patients were either ASA grade 1 or 2 compared to ASA grade 3 (RR=2.7, 95%CI 1.0–7.3, p=0.06). The reasons given by the treating surgeon for not performing THR in eligible patients were multifactorial. Conclusion. There is significant variation in the provision of THR for eligible hip fracture patients which is influenced by both patient demographics and also by the unit to which the patient is admitted

Fractured neck of femur is a significant health concern within the UK. NICE guidance on the management of displaced intracapsular fractures states that total hip arthroplasty should be offered when patients can; walk independently out of doors with no more than a stick, not cognitively impaired, medically fit for anaesthesia and the procedure. We previously managed this subgroup using THA with standard sockets. Following an audit of this practice a dislocation rate of 9% was identified and practice was changed to using dual mobility (THA-DM) with the theoretical advantage of reducing dislocation. We reviewed all patients who underwent THA for fracture using Bluespier from 2013–2017. Operative notes and radiographs were reviewed to ensure the patients had undergone THA for displaced intracapsular fracture. Basic patient demographics were collected. Our primary outcome was dislocation rates at one year. Our secondary outcomes were length of time to surgery, length of stay, operative time, mortality, return to theatre rates and one year Oxford hip scores. We found a control group of 45 THA procedures and a dual mobility group of 143 procedures. The one year dislocation rate from the THA-SS group was 9% and the THA-DM group was 1.4%(CI±1.9%)(p=<0.05%). There were also non-significant reductions in time to surgery, length of stay, operative time, mortality, return to theatre rates. The one year Oxford hip score was comparable at 42.2 to 41.8. This study demonstrates a significant reduction in one year dislocation rates with comparable oxford hip scores. Use of THA-DM should be considered in those patients who meet NICE criteria. Further research is needed into long term dislocation rates

The displaced intracapsular fracture in the elderly has frequently been termed the ‘unsolved’ fracture because of the debate as whether the femoral head should be preserved or replaced. To answer this question 413 patients aged over 70 years with a displaced intracapsular fracture were entered into a prospective randomised trial, to treatment with either an uncemented Austin Moore hemiarthroplasty or reduction and fixation with three cancellous screws. Pathological fractures, Paget’s disease and rheumatoid arthritis patients were excluded. Analysis of pre-operative characteristics of patients showed there was no significant difference between the two groups. Mean follow-up of surviving patients was 827 days. Internal fixation resulted in a reduced mean operative time (22 versus 47 minutes), operative blood loss (23ml versus 171mls) and transfusion requirements. There was no significant differences in the incidence of post-operative complications between treatment other than and increased risk of wound sepsis for arthroplasty (4/207 versus 0/206 deep wound infections). There was a consistent tendency to a marginally lower mortality following internal fixation (15.5% versus 12.7% at 90 days). Six patients in the arthroplasty group required revision, four for loosening, one for sepsis and one for fracture around the implant. Non-union occurred in 64(31%) of those treated by internal fixation. Most of these patients had conversion to arthroplasty. Other complications of internal fixation requiring secondary operations were avascular necrosis (4 cases), fracture below implant (1 cases) and removal for painful screw heads (7 cases). Functional assessment of the survivors at one year from injury showed no significant difference between the two groups for pain or change in mobility. These results indicate that arthroplasty for displaced intracapsular fractures in the elderly is associated with a reduced re-operation rate but at the expense of a marginally increased mortality

Aim: Alcohol-abuse is a well-recognised problem in the West of Scotland. This retrospective case-note study aims to assess the presentation, management and early outcome of alcohol-abusing patients sustaining displaced intracapsular fractures compared to age-matched controls. Methods: Patients were identified from a prospectively-collected database of trauma admissions from 1998 to 2002. Alcohol-abuse was defined by documented evidence of excessive and chronic alcohol intake. Results: 35 alcohol-abusing patients under the age of 65 (mean age 57.5 years) with displaced intracapsular fractures were identified and followed-up for a mean of 3.87 years, and compared with 39 age-matched controls (mean follow-up 3.35 years). There was a significant difference between groups in interval between injury and surgery, with alcohol-abusers undergoing surgery 40.2 hours after injury compared to 22.2 hours for controls (p=0.039). Post-operative stay was also significantly different, with discharge at 7.0 and 5.0 days post-operatively for abusers and controls respectively (p=0.002). 26% of abusers required increased level of care after discharge compared with 15% of non-abusers, although this did not reach statistical significance. Reduction and fixation was employed in 26 alcohol-abusing patients and 30 controls. Early postoperative complications were similar in both groups with the exception of delirium tremens (17% of abusers). Of patients treated with internal fixation, four patients in the alcohol-abuse group required revision surgery (15%) compared to three of the control group (10%, no significant difference). Two patients within the abusers group developed avascular necrosis (7.7%) compared to three within the control population (10%, no significant difference); only two of these five required revision surgery with femoral head replacement. During the follow-up period, alcohol-abusers had a five-fold higher rate of subsequent fractures of their contralateral hip or elsewhere (p=0.02). Conclusions: Alcohol-abusing patients with displaced intracapsular fractures have an increased economic burden compared to controls requiring longer inpatient stays and more frequent subsequent fractures. However, despite increased intervals between injury and surgery, this study finds no evidence that they are at greater risk of failure of internal fixation as compared to controls

Intoduction: There is a general consensus with regard to the treatment of extacapsular fractures of the hip, however the surgical treatment and the choice of implant in displaced intracapsular fractures remains controversial. Evidence has not definitively established the relative merits of the optimal device for internal fixation. The management of displaced intracapsular femoral neck fractures depends on surgeon’s preference. Methods: We have done a study using synbone (Corticocancellous with similar properties of natural bone) comparing three methods of fixation (three parallel cannulated screws, two hole dynamic hip screw with and without a derotation screw, four constructs of each fixation). We looked at the ultimate peak loads that a construct can withstand before failure. Results: There is a significant difference between the cannulated screws and two hole Dynamic hip screw, the latter being stronger of the two. However there is no biomechanical advantage of using the derotation screw. Discussion: Although this study provides evidence of superiority of dynamic hip screw over cannulated screws, this is limited to the biomechanical properties of the construct. The ultimate clinical failure can depend on numerous other factors. Based on our study we recommend two-holed Dynamic Hip Screw fixation for displaced intracapsular fractures of proximal femur

Objective. The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation. Patients and methods. A total of 197 patients with displaced intracapsular fracture of neck of femur, all of whom have been treated with closed reduction and internal fixation, were studied. The mean age was 71 years and 79% were female. Patients were followed up until fracture endpoint (union or non-union) with minimum follow up of 200 days. Results and conclusion. 118 (60%) of the fractures achieved clinical and radiological union. The mean body weight for the patients achieved fracture union was 64.6 kilograms versus 61.6 kilograms for those who developed fracture non union or avascular necrosis of the femoral head (p value for the difference p=0.15, not statistically significant). This study is the largest study indicates that the patient's weight is not an indicator of later fracture healing complications

Intra-capsular fracture neck of femur in a young patient is a surgical emergency. Results of internal fixation with cannulated screws to date show high rates of non-union and of avascular necrosis. This leading to a high rate of re-operation with cannulated screws. A tendency therefore is to lean toward total arthroplasty of the hip in the instance of displaced fracture of the neck of femur. We discuss both the biomechanical and biological reasons for failure of internal fixation of displaced fractures of the neck of femur with cannulated screws, and criteria required to provide adequate fixation of these fractures to allow union and avoid osteonecrosis. We consider other methods of fixation of displaced intracapsular fractures and analyse illustrative cases demonstrating these methods. In view of the precarious biological milieu of displaced intracapsular fractures of the neck of femur, we feel that the use of cannulated screws is a poor fixation method. Therefore the option of internal fixation should not be abandoned in favour of arthroplasty because of poor results from this one biologically and biomechanically inadequate operation

To determine the optimum choice of treatment for the displaced intracapsular fracture in the elderly, 455 patients aged over 70 years with a displaced intracapsular fracture were entered into a prospective randomised trial. Treatment was either an uncemented Austin Moore hemiarthroplasty or reduction and internal fixation with three AO cancellous screws. Analysis of pre-operative characteristics of patients showed there was no significant difference between the two groups. Follow-up of surviving patients was continued for between seven to 15 years to determine the long-term outcome for the two treatment Methods: 90% of patients died during this follow-up period. Regarding short term outcomes, internal fixation resulted in a reduced mean operative time, operative blood loss and transfusion requirements. There was no significant difference in the length of hospital stay or incidence of general post-operative complications. There was no difference in either the short term or long-term mortality between the two procedures. The need for revision surgery to the hip was increased for those treated by internal fixation (7% versus 38% implant revision rate). There was no difference in the degree of residual pain between groups neither was there any difference in the number of patients requiring institutional care. There was a tendency to slightly better mobility for those treated by internal fixation although the Results: were not statistically significant. These results demonstrate that both treatment methods produce comparable final outcomes but internal fixation is associated with an increased re-operation rate

Introduction: Despite its common occurrence there is still controversy regarding the choice of treatment for the displaced intracapsular hip fracture in the elderly patient. Aim: To compare internal þxation and hemiar-throplasty in a prospective randomised controlled trial. Method: 455 patients aged over 70 years with a displaced intracapsular hip fracture were randomised to either hemiarthroplasty or internal þxation. Results: Internal þxation has shorter length of anaesthesia (p< 0.0001), lower operative blood loss (p< 0.0001) and lower transfusion requirements (p< 0.0001). Additional surgical procedures were required in 90 patients (39.8%) treated by internal þxation and 12 patients (5.2%) in the arthroplasty group. There was no statistical difference in mortality at one year (p=0.91), however there was a trend to improved survival for the older less mobile patients treated by internal þxation. There was no statistical difference in pain and mobility. Limb shortening was more common after internal þxation (p=0.004). Conclusion: We recommend that displaced intracapsular fractures in the elderly should generally be treated by hemiarthro-plasty, but internal þxation may be appropriate for the frail less mobile patient

Aims: Our study was designed to compare a series of elderly individuals who sustained a displaced femoral neck fractures treated with either a bipolar prosthesis or a modular unipolar prosthesis. Methods: In a level I orthopaedic trauma center, 140 from 234 consecutive patients with displaced intracapsular fractures of the proximal femur (Garden Types III-IV) underwent primary prosthetic replacement. 122 of them received a bipolar prosthesis (68 patients 55.7%) or a modular unipolar prosthesis (54 patients Ð 44.3%). The mean age was 62 years. Results: 24 patients died during the period of study and 32 patients were lost to follow-up. Consequently, 66 patients were followed for a minimum 18 months: 34 in the bipolar prosthesis group and 32 in the modular unipolar prosthesis group. Functional status of the hip was compared between both groups, as well as the incidence of complications or need for revision surgery. No signiþcant differences were found between the bipolar and unipolar group. Conclusions: Either bipolar or modular unipolar hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture of the proximal femur in elderly patients. The incidence of the acetabular erosion in the unipolar group may demonstrate the theoretical beneþt of the bipolar prosthesis, although the differences were not statistically signiþcant

Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. This is likely to have significant logistical implications for individual departments. Data from the National Hip Fracture Database was analysed retrospectively between January 2009 and November 2011. The aim was to determine if patients with displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit received a THA if they met NICE criteria. Case notes were then reviewed to obtain outcome and complication rates after surgery. Five hundred and forty-six patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. Sixty-five patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16: 49); however, 21 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 1 dislocation and 2 required revision to a THA. There is evidence to suggest better outcomes in this cohort of patients, in terms pain and function. There is also a forecasted cost saving for departments, largely due to the relative reduction in complications. However, there were many cases (44) in our department, which would have been eligible for a THA, according to the NICE guidelines, who received a hemiarthroplasty. This is likely a reflection of the increased technical demand, and larger logistical difficulties faced by the department. We did note more complications within the hemiarthroplasty group, however, the numbers are too small to address statistical significance, and a longer follow up would be needed to further evaluate this. There is a clear scope for optimisation and improvement of infrastructure to develop time and resources to cope with the increased demand for THA for displaced intracapsular neck of femur fractures, in order to closely adhere to the NICE guidelines

Treatment of displaced intracapsular fracture of the hip by hemiarthroplasty in old patients is generally satisfactory. Middlemore Hospital’s agreed criteria for hemiarthroplasty were reviewed and tested. Two hundred and thirty three patients who had hemiarthroplasty for displaced intracapsular fracture neck of femur between June 199- June 2001. All the patients’ data collected from the hospital computer system and then a search started for these patients to review their current status regarding pain and mobility. Ninety nine patients (42%) were still alive, of them 13 demented, 13 moved or lost and 7 in a wheel chair. Sixty six patients reviewed for pain and mobility using Sikorski and Barrington scoring criteria for pain and mobility. Thirteen patients had painful hemiarthroplasty. Clinical notes of the most active group of these patients (7 patients) reviewed individually to identify the causes. Two patients had revision to total hip joint replacement within 3 months because of technical errors and two patients placed on the waiting list for revision. The rest had deterioration in their general health that made total hip arthroplasty a risky operation for them. The revision rate was 1.7 %. We concluded that hemiarthroplasty was an acceptable option for these patients. The selection criteria were correct in 98.2% of the cases. Patients who live in their own home will need a careful assessment before deciding on a hemiarthroplasty for them

Introduction: Fractures of the neck of femur has a considaerable impact on the NHS and due to the elderly group of population it involves morbidity can be very costly. We assesed the outcome of trauma patients with these fractures after providing orthogeriatric care in our hospital. Aim: 179 patients had been studied who had been managed in our hospital over a period of 18 months with hemiarthroplasty for displaced intracapsular fracture of the neck of femur. 104 patients had routine orthopaedic care and 75 patients had regular orthogeriatric care. All the complication were noted, analysed and compared with the national averages. Methodology: This was a retrospective study-clincal notes of all patients who had hemiarthroplasty during the 18 month period were reviewed and a performa was completed. Result: Total sample size was 179 patients(104 before and 75 after the introduction of orthogeriatric service) who had hemiartroplasty for the displaced intracapsular fracture of the neck of femur. The median length of stay being 16.5 days before and 20 days after. The medical complications before and after the introduction of this service were-Cardiac complication 4% before and 1% after, Chest infection 2% before and 1% after, DVT 2% before and 1% after. The Overall complication rate has been reduced from 41% to 18% and the one year mortality reduced from 16.34% to 12 with the introduction of orthogeriatric service. Conclusion: We believe that the weekly ward round and a continued supervision by the orthogeriatric team is one of the factors in improving the outcome of geriatric trauma patients in terms of reduced morbidity and mortality

Introduction: The best method of management of displaced intracapsular femoral neck fractures in elderly patients remains undecided. Most are treated by hemiarthroplasty. Aim: To clarify the issue of whether or not to use cement in hemiarthroplasty for displaced, intracapsular, femoral neck fractures in the elderly. Methods: Consecutive patients with displaced, intracapsular, femoral neck fractures treated by hemiarthroplasty between January 1997 and May 1998, in two hospitals within one region were reviewed. The same monoblock prosthesis was used; in Hospital A they were uncemented (121 patients), and in Hospital B they were cemented (123 patients). All surviving patients (50 and 56 respectively) were interviewed for assessments of pre-fracture and current pain, walking ability, use of walking aids and activities of daily living (ADL), using validated scoring systems. The average follow-up was 36 months. Results: The patients’ demographical data were similar (the mean age was 82 and 84 years respectively). There was no greater incidence of intra-operative fall in diastolic blood pressure or oxygen saturation in the cemented group. Cemented procedures took, on average, 15 minutes longer. Fewer of the cemented group had been revised or were awaiting revision (p=0.036). There was no difference in complication or mortality rates at any time between surgery and follow-up (p=0.86). Prospective assessment revealed highly significant differences in favour of cement, in terms of pain (p=0.003), walking ability (p=0.002), use of walking aids (p=0.004) and ADL (p=0.009). Conclusion: Our findings support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient

Background. Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes. Design. This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset. Discussion. Evidence on the optimum choice of prosthesis for hemiarthroplasty of the hip is lacking. National guidance is currently based on expert opinion rather than empirical evidence. The incidence of hip fracture is likely to continue to increase and providing high quality evidence on the optimum treatment will improve patient outcomes and have important health economic implications. Cite this article: A. L. Sims. The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation – WH. I. TE 3: HEMI – An Abridged Protocol. Bone Joint Res 2016;5:18–25. doi: 10.1302/2046-3758.51.2000473