Aims

This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries.

We have investigated whether the pattern of subchondral acetabular cyst formation reflects hip pathology and may provide a prognostic indicator for treatment. A single surgeon series of sequential hip arthroscopies was reviewed to identify the most recent 200 cases undertaken on a previously un-operated joint with pre-operative plain radiographs and computed tomography or magnetic resonance scan available for review. Also, serial “non-arthritic hip scores” (NAHS) recorded pre-operatively, at 6 weeks and 3 months post-surgery. The acetabular Lateral Centre Edge Angle, the Acetabular Index, the FEAR index and the Kallgren and Lawrence grade were determined. All images were reviewed by two independent assessors and divided into four groups according to acetabular subchondral cyst distribution. NC - No cysts - 74 cases (mean: 40.1 years), SPC - a Single Peripheral Cyst – 58 cases (mean: 43.1 years), SDC - a Solitary Dome Cyst – 32 cases (mean: 33 years) and MC - Multiple Cysts – 36 cases (mean: 42.7 years). No association was identified between gender and patient reported outcomes. SDC patients were significantly younger than the other three groups (p <0.001). At three months after surgery, the average increase of the NAHS in the four groups was 25.3, 23.5, 4.2 and 4.9 respectively. Acetabular dysplasia was identified in 72% of the SDC group compared to 18%, 16% and 33% in NC, SPC and MC groups. Degenerative change was identified in 86% of the MC group compared to 18%, 40% and 41% of the NC, SPC and SDC groups. The early patient reported outcome following hip arthroscopy was significantly affected by the location and number of acetabular subchondral cysts. A Solitary Dome Cyst is indicative of underling hip dysplasia. Multiple Cysts are indicative of degenerative disease. The majority of patients in these groups have poor three-month outcomes after hip arthroscopy

Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.

Arthroscopic procedures are increasingly performed for femoroacetabular impingement (FAI). The Non-Arthroplasty Hip Register (NAHR) collects data including the iHOT12 and EQ5D. However there is currently little evidence of its usefulness in assessing hip arthroscopy outcomes. This study aims to assess minimum 1-year outcomes of hip arthroscopy for FAI using the minimum data set (MDS) of the NAHR by comparing these to a patient satisfaction questionnaire. Pre-operative scores for 78 consecutive hips in 76 patients (43F/33M, mean age at surgery 31.76±10.02 years) undergoing hip arthroscopy for FAI at our institution between February 2013-June 2015 were entered into the NAHR. Insufficient post-operative data was available from the registry. Therefore we collected iHOT12, EQ5D and satisfaction data by postal survey. Preoperative mean iHOT-12 score was 32.67±14.23, median EQ5D Index score 0.653 (IQR 0.277) and median EQ5D Visual Analogue Scale 70 (IQR 25). Postoperative scores were available for 56 cases (55 patients, 71.8%) at median 18.9 months (IQR 13.77). There was a significant postoperative improvement in self-reported outcome as measured by iHOT-12 (mean improvement 35.7 points, p<0.001) and EQ5DIndex scores (median improvement 0.127, p=0.001). 24 patients were very satisfied, 19 satisfied, 6 neutral, 4 dissatisfied and 1 very dissatisfied. Satisfied patients exhibited greater improvement in iHOT-12 (mean 41.64±19.29 vs 2.8±24.08, p<0.001) and EQ5D index scores (p=0.013) but no difference in EQ5D VAS (p=0.15). Improvement in iHOT12 correlated with improvement in EQ5DIndex (r=0.676, p<0.001) and EQ5DVAS(r=0.552, p<0.001). Hip arthroscopy for FAI yielded significant improvements in iHOT-12 and EQ5D index scores and 80% of responders were satisfied/very satisfied at a minimum one year postop. iHOT12 and EQ5DIndex correlated with patient satisfaction and improvements in iHOT12 correlated with improvements in general quality of life. Our findings suggest that the MDS of the NAHR is useful for assessing the outcome in these patients

Hip arthroscopy is becoming more popular. A literature review demonstrated paucity of published papers reporting the outcome of hip arthroscopy in teenagers without developmental dysplasia of the hip. Our aim was to record the type of lesions found and report the outcome and level of satisfaction following hip arthroscopy in teenagers. From 2002 to 2008, 96 hip arthroscopies were undertaken in 76 patients. Pre-operative and two-week, six-week and current post-operative assessments were performed using the modified Harris hip score (HHS) and the Non Arthritic Hip Score (NAHS). In addition, a satisfaction survey was completed at their most recent review. Patients enrolled in the study were under the age of 20. Patients with a history of developmental dysplasia of the hip, Perthes disease and arthritis were excluded from the study. Patients had at least a six-month follow-up from their surgery. Our study cohort comprised 53 males and 43 females with an average age of 17 years old (range 13 to 19 years). The average duration of follow up was 19 months (range 3 to 75 months). There were 41 left and 54 right-sided hip arthroscopies. There were five re-operations. The average duration of hip traction was 19 minutes (range 6 to 47 minutes). We found pathology in all hips that underwent arthroscopy. We report a significant improvement in MHHS and NAHS at six weeks and current review (p-value <0.01). Sixty-two percent of patients had returned to sport at the previous level of competition, 32% of patients returned to sport at a lower level of competition and 5% patients did not return to sport. Overall, 84% of patients were satisfied following their hip arthroscopy and 91% would have the surgery again if they had to. There were five re-operations. Our study has revealed a range of intra articular hip pathologies amenable to surgical treatment using hip arthroscopy. We have observed a significant improvement in hip scores; with up to 94% of patients returning to sport in the short term with high satisfaction levels. Long term follow up of this group is ongoing

Background

This study aimed to investigate the effect of body mass index (BMI) on functional outcome following hip preservation surgery using the U.K. Non-Arthroplasty Hip Registry (NAHR).

Background of study

There has been an exponential increase in the use of direct thrombin (DT) and factor Xa inhibitors (FXI) in patients with cardiovascular problems. Premature cessation of DT/FXI in patients with cardiac conditions can increase the risk of coronary events. Our aim was to ascertain whether it is necessary to stop DT and FXI preoperatively to avoid postoperative complications following hip fracture surgery.

Background and aim

Since the market withdrawal of the ASR hip resurfacing in August 2010 because of a higher than expected revision rate as reported in the Australian Joint Replacement Registry (AOAJRR), metal-on-metal hip resurfacing arthroplasty (MoMHRA) has become a controversial procedure for hip replacement. Failures related to destructive adverse local tissue reactions to metal wear debris have further discredited MoMHRA. Longer term series from experienced resurfacing specialists however, demonstrated good outcomes with excellent 10-to-15-year survivorship in young and active men. These results have recently been confirmed for some MoMHRA designs in the AOAJRR. Besides, all hip replacement registries report significantly worse survivorship of total hip arthroplasty (THA) in patients under 50 compared to older ages. The aim of this study was to review MoMHRA survivorship from the national registries reporting on hip resurfacing and determine the risk factors for revision in the different registries.

Methods: We examined prospectively collected data from 6782 consecutive hip fractures to identify 327 fractures in female patients aged 65 years and younger. We report on demographic characteristics, treatment and outcome. We compare this group with a cohort of 4810 consecutive hip fractures in older females.

Results: Not surprisingly, younger women had higher levels of mobility and independence than their older counterparts. However, over 20% mobilised with aids, needed help with activities of daily living and/or had significant co-morbidity. A significantly higher proportion of younger patients were smokers. This had a strong influence on the relative risk of “early” as opposed to “late” fracture (Hazard Ratio 4.7, p< 0.01). Mortality was 0.7% at 30 days and 4.2% at one year.

We calculated age-related incidence of hip fracture in the local population and noted the first significant increase at the interval between 40–44 and 45–49, rather than the age of 50, which is when the onset of screening of hip fracture patients for osteoporosis occurs in most health areas. Lag screw fixation was the most common method of operative fixation. General complication rates were low, as were reoperation rates for cemented prostheses. Intracapsular fractures are an interesting subgroup. When displaced, 39% (61/158) had lag screw fixation and 61% (97/158) were treated by arthroplasty. Kaplan-Meier implant survivorship of displaced intra-capsular fractures treated by reduction and lag screw fixation was 82% at two and 71% at five years.

Conclusion: Hip fractures in females to 65 years of age are sustained by a population at risk as a result of patho-physiology. Treatment in this age group, particularly of intracapsular fractures, remains a topic of debate. Understanding the characteristics of these patients, may lead to an improved opportunity, if not for prevention, at least for intervention.

Background

Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery.

It has been recently suggested that hyponatraemia may be a cause of significant iatrogenic harm in orthopaedic patients. In an attempt to test this theory, this observational study was done to establish the incidence of post-operative hyponatraemia following hip fracture and evaluate its correlation with outcome.

An observational study was carried out on 213 consecutive hip fracture patients. 201 patients completed the requirements of the study (Male-45, Female-156). Mean age was 80 years. Serum sodium concentrations were recorded during the first week of admission. Hyponatraemia defined as significant (Na < 130mmol/L) was identified in 9% at admission and 18% during first week of stay. Incidence of severe hyponatraemia was 3%. There were no acute complications of hyponatraemia in these patients. 78% of hyponatraemia patients had received 5% Dextrose infusion during the postoperative period as their main intravenous fluid. All hyponatraemic patients had their sodium levels restored to normal during their stay.

Long term outcome measures used were mortality, change in residential status, walking ability and use of walking aids at 4 months following fracture. There was 20% mortality at 4 months in the hyponatraemic group and it was 30% in the normal serum sodium group. However this difference was not statistically significant. Hyponatraemia did not significantly influence deterioration in residential status (p< 0. 05), walking independence (p< 0. 05) or increase of walking aids (p< 0. 05).

In hip fracture patients, hyponatraemia whilst common was not associated with a poor outcome and at the same time we did not find any evidence of lapse in the recognition and treatment of hyponatraemia in a general orthopaedic ward. However emphasis should be made to junior medical staff to avoid iatrogenic hyponatraemia by following a proper postoperative fluid regime.

Reasons for failure of hip resurfacing arthroplasty include femoral neck fracture, loosening, femoral head osteonecrosis, metal sensitivity or toxicity and component malpositioning.

Patient factors that influence the outcome include prior surgery, body mass index, age and gender, with female patients having two and a half times greater risk of revision by 5 years than males 1–4. In 2008, the Australian National Joint Replacement Registry (ANJRR) reported poorer results with small sizes, whereby component sizes 44mm or less have a five times greater risk of revision than those 55mm or greater 1. This finding is true for both males and females and after accounting for femoral head size, the effect of gender is eliminated.

We explore the relationship between component size and the factors that may influence the survivorship of this procedure, resulting in higher revision rates with smaller components.

These include femoral neck loading, edge loading, wear debris production and the effects of metal ions, cement penetration, component orientation, and femoral head vascularity. In particular the way the components are scaled from the large sizes down to the smaller sizes results in some marked changes in interactions between the implant and the patient.

Wall thickness of the acetabular and femoral component does not change between the large and small sizes in most devices. This results in a relative excessively thick component in the small sizes. This may cause more acetabular and femoral bone loss, increased risk of femoral neck notching and relative undersizing of the component where acetabular bone is a limiting factor. Stem thickness does not change throughout the size range in many of the devices leading to relatively more femoral bone loss and a greater stiffness mismatch between the femoral stem and the bone. Relatively stiffness between the femoral stem and the bone is up to six times greater in the small size compared to the large size in some designs.

The angle subtended by the articular surface (the articular arc) ranges from 170° down to as low as 144° in the small sizes of some devices. A smaller articular arc increases the risk of edge loading, especially if there is any acetabular component malpositioning. Acetabular inclination has been related to metal ion levels 5 and to the early development of pseudotumour6.

An acetabular component with a radiographic inclination of 45° will have an effective inclination anywhere from 50° to 64° depending on the type and size of the component. This corresponds to a centre-edge angle from 40° down to 26°. The effective anteversion is similarly influenced by design.

The result of a smaller articular arc is to reduce the size of the ‘safe window’ which is the target for orthopaedic surgeons.

Introduction: Obesity is detrimental to the health of an individual, however does a high body mass index (BMI) actually determine post operative morbidity following hip replacement surgery?

Methods: 550 consecutive primary hip replacement patients were included in this study. Patients were followed up at four weeks, six weeks and one year following surgery. Any complication that the patient had was recorded and listed either as local or general. The complications were further sub divided into minor and major depending on the risk they posed to the patient or the joint.

Results: The average BMI of our patients was 28.3 (4.3). 56 (10%) patients had a complication following hip replacement surgery. The group who did not have any complications had an average BMI of 28.13 (SD=4.6) while the group who sustained complications had an average BMI of 29.46 (SD=5.8) with a p value of 0.104 (Student t-test). When BMI was grouped in values of 5 starting from < 25 and ending with > 35 the p value was 0.029 (chi square test). Odds ratios for grouped BMI varied from 0.086–1.61(95% CI 1.01–1.08) (p=0.086). Odds ratios for individual surgeons ranged from 0.96–2.41 (p=0.024)

Discussion: When we looked at the overall BMI there was no significant difference between the group who had a complication and the group who did not have a complication, however when the BMI was split into groups those patients in group 30–34 and 35+ experienced a higher rate of complications. The final odds of BMI was 1.05 (1.01,1.09). There was a higher complication rate in the groups other than the ideal BMI of 25–29, and even a fall in BMI caused an increase in the complication rates.

Conclusions: Obese individuals are at a higher risk of developing a complication following surgery, however the operating surgeon also has an influence on the complication rate following hip replacements.

Background

Periprosthetic joint infections (PJI), caused by pathogens, for which no biofilm-active antibiotics are available, are often referred to as difficult-to-treat (DTT). It is unclear whether DTT PJI has worse outcome due to unavailability of biofilm-active antibiotics. We evaluated the outcome of DTT and non-DTT PJI managed according to a standardized treatment regimen.

Introduction: Although Hip Resurfacing Arthroplasty (HRA) has become a popular alternative to THR, the outcome of these procedures varies extensively between centres. This has been attributed to variations in patient selection, surgical experience, and patient volume. In this study we examine the effect of hospital volume on the outcome of hip resurfacing using a national database.

Methods: We examined data collected by the Australian Joint Registry between September 1999 and December 2006 relating to 8945 hip resurfacing procedures performed in 196 hospitals. Survivorship of the implanted components was calculated with revision as the end-point. The cumulative rate of revision at 4 years was compared between hospitals as a function of the number of cases performed during the study period (< 25, 25–49, 50–100, > 100 procedures). Using the log-rank test, differences in the risk of revision, corrected for age and sex of patients, were compared for low (< 25 cases) vs. higher volume centres (> 25 cases). We also estimated the number of cases/year of each centre and examined its apparent impact on revision rate.

Results: The majority (74%) of hospitals reporting performed less than 30 resurfacing procedures over the 7 year study period, with 64% of procedures performed at 16 “high volume” hospitals (> 100 cases), Overall, 249 of the 8945 resurfacing procedures (2.9%) were performed for revision of the original components. At 4 years, the cumulative revision rate dropped from 5.8% for hospitals performing less than 50 cases to 4.7% (50–99 cases) and 2.7% (> 100 cases) for larger volume centres. When adjusted for differences in patient age and sex, the risk of revision was 66% higher in hospitals performing < 25 cases. Based on the available data, the gap in revision rate between high and low volume centres is reduced by 50% once a surgeon’s operative volume exceeds 6 cases per year. On average, this corresponds to a learning curve of approximately 5 cases.

Conclusions: In this study, hospital volume is primarily a reflection of the operative experience of individual surgeons. Our results show that the outcome of hip resurfacing is strongly dependent on the experience of the surgeon and hospital performing the procedure. Even when adjusted for age and sex of the patients, the risk of revision increased by 66% when cases were performed at low volume centres. This supports the need for increased training of surgeons before undertaking hip resurfacing.

There is a known association between femoroacetabular impingement (FAI) and osteoarthritis of the hip. What is not known is whether arthroscopic excision of an impingement lesion can significantly improve a patient’s symptoms.

This study compares the one-year results of hip arthroscopy for cam-type FAI in two groups of patients. The study (osteoplasty) group comprised 24 patients (24 hips) with cam-type FAI who underwent arthroscopic debridement with excision of their impingement lesion. The control (no osteoplasty) group comprised 47 patients (47 hips) who underwent arthroscopic debridement without excision of their impingement lesion. In both groups, the presence of FAI was confirmed on pre-operative plain radiographs. The modified Harris hip score (MHHS) was used for evaluation pre-operatively and at one year’s follow-up. Non-parametric tests were used for statistical analysis.

A tendency towards higher median post-operative MHHS scores was observed in the study than in the control group (83 vs. 77, p = 0.11). This was supported by a significantly higher portion of patients in the osteoplasty group with excellent/good results (83% vs. 60%, p = 0.043). It appears that even further symptomatic improvement may be obtained after hip arthroscopy for FAI by means of the femoral osteoplasty. When treating cam impingement arthroscopically, both central and peripheral compartments of the hip should always be accessed.

Introduction and Aims: There is a known association between femoroacetabular impingement (FAI) and osteoarthritis of the hip. What is not known is whether arthroscopic excision of an impingement lesion can significantly improve a patient’s symptoms.

Materials and Methods: This study compares the one-year results of hip arthroscopy for cam-type FAI in two groups of patients. The study (osteoplasty) group comprised 24 patients (24 hips) with cam-type FAI who underwent arthroscopic debridement with excision of their impingement lesion. The control (no osteoplasty) group comprised 47 patients (47 hips) who underwent arthroscopic debridement without excision of their impingement lesion. In both groups, the presence of FAI was confirmed on pre-operative plain radiographs. The modified Harris hip score (MHHS) was used for evaluation pre-operatively and at one year’s follow-up. Non-parametric tests were used for statistical analysis.

Results: A tendency towards higher median post-operative MHHS scores was observed in the study than in the control group (83 vs. 77, p = 0.11). This was supported by a significantly higher portion of patients in the osteoplasty group with excellent/good results (83% vs. 60%, p = 0.043).

Conclusions: It appears that even further symptomatic improvement may be obtained after hip arthroscopy for FAI by means of the femoral osteoplasty. When treating cam impingement arthroscopically, both central and peripheral compartments of the hip should always be accessed.

Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a major element of this but no consensus exists as to the detection or management of this condition. Reported incidence in elderly hip fracture patients varies widely between 9.0% and 88.6%.

The aim of this study was to evaluate the nutritional status of 415 patients with operatively managed hip fractures and determine the prognostic relevance of admission serum albumin and total lymphocyte count (TLC) assays. Protein-energy malnutrition (PEM) was defined as serum albumin < 3.5g/dl and a TLC < 1,500 cells/mm3. Delay to operation, duration of in-patient stay, re-admission (< 3 months) and in-patient, 3- and 12-month mortality were assessed as outcome variables.

Survival data was available for 377 patients at 12 months. Of 377 patients, 53% (n=200) had both a serum albumin and TLC levels taken at admission, while 47% (n=177) had not. The incidence of PEM was 51%. Inhospital mortality for PEM patients was 9.8%, compared with 0% for patients with normal values of both laboratory parameters. Older patients were more likely to have lower albumin (p=0.017) and TLC (p=0.023). Nursing home patients were also more likely to have lower albumin (p=0.033). Multivariate analysis revealed a significant difference in 12-month mortality, with patients who had both a low albumin and a low TLC 4.6 times (95% CI: 1.0–21.3) more likely to die within 12 months postoperatively than patients who had normal values of both laboratory parameters. This was significant after adjusting for age, gender and domicile (p=0.049).

Serum albumin and TLC in combination are accurate predictors of 12-month mortality in hip fracture patients. These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the relationship between nutrition and outcome.

Aim: Many risk factors for DDH are well documented. This study was undertaken to investigate whether multiple pregnancy is a risk factor for developmental dysplasia of hips. Method: During a 10-year period from 1989 to 1998, 39826 newborn babies had their hips scanned. Of these, 1022 (2.6%) babies were non-singletons. Inclusion criteria for our study were all non-singletons, who had their hips scanned in the þrst week after birth. We analyzed the results of their hip scans and calculated the risk for developing DDH either alone or with other risk factor and other variables like the gender, mode of delivery, birthweight and the length of pregnancy. Results: Of the 1022 babies, 825 (80.7%) had their hips scanned in the þrst week. M: F: 49.6%: 50.4%. We had 397 sets of twins, 9 sets of triplets and 1 set of quadruplet. 78% of this group had a normal presentation. 21% (181) of these babies were breech. There was no family history associated with any of the multiple births. Ultrasound abnormality was seen in 30 hips (1.8%). 1 patient had Pavlik harness treatment for persistent ultrasound abnormality. No signiþcant correlation was seen in the gender or in the length of pregnancy. Conclusion: Though it is a general impression that the hips of the non-singletons are under high mechanical stress during pregnancy and would be expected to have a relatively high incidence of DDH, from our study it is evident that the risk is no greater than the normal singletons.

A prospective study of 142 consecutive patients admitted with fracture of the neck of femur was performed. 42 patients were operated within 24 hours of time of fracture (group 1), 46 within 24 to 48 hours (group 2) and 47 more than 48 hours later (group 3). Three patients were treated conservatively and in four patients the exact time of fracture was not known.

The reason for delay of the operation was lack of theatre space in the majority of cases (64 patients). Medical problems accounted for delay in only 10 patients.Seven patients out of 42 in group 1 died within four month (16.7%), compared to 11 of 46 in group 2 (23.9%), and 6 out of 47 in group 3 (12.8%). This difference was not statistically significant.

There was no significant difference in requirement for pre- and postoperative blood transfusion between the three groups. No patient operated within 24 hours developed pressure sores. Three patients in group 2, and six patients in group 3 developed pressure sores. Chest infections occurred in three patients in group 2, and in three patients in group 3. None of the patients operated on within 24 hours developed a chest infection, wound infection or urinary tract infection. Two patients who had a Girdlestone procedure for deep infection were operated more than 48 hours after the fracture. One patient requiring drainage for wound infection had the operation 47 hours after the fracture.There were no superficial or deep wound infections, pressure sores, or chest infections if operated on within 24 hours of fracture. There was no difference in the requirement for blood transfusion. Patients operated within 24 to 48 hours of fracture had the highest mortality, although this was not statistically significant.