Salvage Total Hip Arthroplasty (THA) presents a viable solution following failed treatment of a hip fracture. Several studies have suggested higher complication rate including high dislocation rate associated with salvage THA. The present study evaluates the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of a hip fracture and comparison made to Primary THA in osteoarthritis (OA). Between 1992 and 2007, 53 patients with a mean age of seventy years were treated with THA after the failed treatment of a hip fracture under the care of a single surgeon. The indication for conversion arthroplasty was Avascular necrosis head – 24(45.3%), screw cut out – 6 (11.3%), non-union – 2(3.8%), Displaced fracture – 2(3.8%), Secondary OA – 19 (35.8%). The implants retrieved were Cannulated screws – 3, Sliding plate and screw – 46, Spline plate – 2, Smith Petersons nail – 1, Martin Plate – 1. This group of patients were matched for age, sex, side, and ASA grading with a group of 59 patients who underwent THA for primary osteoarthritis (THA-OA group). Posterior approach was used in all cases. Four patients (7.5%) required grafting of cup and 21 patients (39.6%) required soft tissue release. The average blood loss was 555 ml, mean duration of surgery was 85.5 min, average inpatient stay was 6.7 days. Cemented THA was used in 43 patients and Cementless THA in 10 patients. At one year follow up there were no dislocations, one patient had an undisplaced femoral fracture treated in Spica. Three patients had broken screws; one patient with shortening > 1 inch. There was one revision for deep infection. The mean Harris Hip Score (HHS) improved from 28.4 to 82.5 at one year, while the Oxford Hip score (OHS) improved from 50.9 to 21.9 (Old system). When the scores were compared to the THA-OA group there was no difference in the oxford hip scores and the the mean one year HHS in the THA-OA group was slightly higher than the group with salvage THA, but the difference was not statistically significant. Hip arthroplasty is an effective salvage procedure in patients with prior surgery for hip fracture. Most patients have good pain relief and functional improvement. Despite the operative challenges, remarkably few serious orthopaedic complications were associated with this procedure in the present study.

Introduction: Historically, it has been accepted that the pain associated with arthritis of the hip is usually located in the groin, anterior and lateral thigh with occasional radiation to the anterior knee. Patients complaining of thigh pain that extends below the knee are often considered to have a degenerative lumbar spine as the cause for their lower limb symptoms and total hip replacement (THR) may not be offered.

Following review of data regarding the preoperative distribution of pain in 2000 patients attending for hip replacement, it was noted that 40% of these patients had complained of pain at or below the knee.

We proposed to prospectively investigate the severity and location of pain in patients attending for THR and assessed how this distribution of pain altered following surgery. We also proposed to examine the distribution of radiological wear preoperatively and assess if there is any relationship between localisation of pain, and the severity or distribution of the radiological wear pattern.

Methods: 200 consecutive patients undergoing primary THR completed a questionnaire regarding the location and severity of their pain. Pain was localised to one or more of nine areas extending from low back to the foot. The localisation of pain was quantified as to severity using a visual analogue score. Questionnaires were completed both 4 weeks preoperatively and subsequently at a 3-month review clinic.

All patients underwent a standardised preoperative AP and Lateral x-ray. The AP film was divided into three areas, and the lateral film was divided into 5 areas. Each zone was assessed as to the severity of wear pattern and graded from 1–3 (no change in joint space, decreased joint space, femoral or acetabular destruction).

Results: The 200 patients complained of pain in a total of 980 areas preoperatively and 105 areas postoperative. 70% of the patients had complete relief of all pain at 3 months. The most common area of pain identified by patients was to the anterior aspect of the knee (82%), followed by pain at the greater trochanter and groin. 55% patients complained of pain extending to below the knee, mostly over the anterolateral aspect of the leg. Only 7% of these patients continued to complain of any below knee pain postoperatively, and all of these patients still had some relief of their below knee pain at review.

With regard to the frequencies and severity of x-ray changes, zone-1 (34%) was most commonly severely damaged with femoral and/or acetabular destruction in the AP film, with the anterior and anterolateral areas being most commonly affected areas in the lateral film (20% and 19% respectively).

When the distributions and severities of x-ray changes were correlated with the distribution of pain localised pre and postoperatively we were unable to show any association between the degree of radiological wear in any one zone and the locatin of pain identified by the patient. In fact, there was a normal distribution to the severity of radiological damage between each of the zones and localisation of pain in any of the 9 areas.

Conclusions: A significant number of patients who require hip arthroplasty have pain extending below the knee. This pain is frequently relieved following THR. The commonest area of sever hip joint wear with loss of femoral or acetabular bone is antero-superiorly. It is important to recognise this during surgery, such that action can be taken to ensure appropriate reaming such that subsequent correct tissue tension and leg lengths are achieved. We are unable to show any relationship between area of pain and area of radiological degeneration. We believe that patients who complain of pain in their back, buttock or thigh, which extends below the knee, can still benefit from total hip replacement. Patients who attend complaining of low back pain with radiation of pain down their leg should have their hips as well as their lumbar spine examined and imaged. Careful consideration should be taken before labelling the paid as being referred from degenerative back disease.

We performed a prospective clinical study in order to assess the effectiveness of repair of the short hip rotators, divided in the course of total hip replacement by the posterior approach, by the use of radio-opaque markers.

Fifteen patients, each with a diagnosis of osteoarthritis of the hip, were selected consecutively from a single surgeon’s operating list. Uncemented Duraloc® acetabular components and custom made cemented femoral components were implanted via the posterior approach in all patients.

Following implantation, the capsule and the short rotator tendons were sutured on to tendinous soft tissue around the greater trochanter using No 1 Vicryl. One radio-opaque marker clip was attached to the short rotators and capsule and a second marker was attached to the greater trochanter.

Standard antero-posterior pelvic X-rays were taken at three to five days post-operatively, and at three months following surgery. Significant separation of the radio-opaque markers in fourteen of the fifteen patients was demonstrated on the day three to five X-ray, indicating failure of the repair.

We conclude that this soft tissue repair is unsatisfactory. It may be of value to develop a more effective repair technique, with the overall aim of reducing total hip replacement dislocation, and as such we are currently investigating a soft tissue to bone repair.

Introduction: Historically, it has been accepted that pain associated with arthritis of the hip is usually located in the groin and thigh with radiation to the anterior knee. However pain below the knee, and into the foot was not believed to be associated with arthritis of the hip. Patients complaining of thigh pain that extends below the knee are often considered to have a degenerative lumbar spine as the cause for their lower limb symptoms, and hip arthroplasty may not be offered. We examined the severity and location of pain in patients attending for arthroplasty and assessed how this altered following surgery.

Methods: 200 consecutive patients undergoing primary total hip arthroplasty completed a questionnaire regarding the location and severity of pain in the leg and also an Oxford hip score to assess functionality. These were completed approximately 4 weeks preoperatively and again at a 3-month review clinic.

Results: 57% (114/200) of patients complained of pain below their knee preoperatively. Only 9% (10/114) of these patients continued to complain of pain postoperatively, and of these patients their mean pain score decreased by 44% (9 to 5). Only 1% (2/200) of all patients complained solely of pain in the knee or more distally, and both of these had complete relief of pain 3 months postoperatively.

Conclusion: A significant number of patients with degenerative hip disease have pain below the knee. Patients who complain of pain in their back, buttock or thigh, which extends below the knee, may still benefit from total hip replacement. Careful consideration should be taken before labelling the pain as being referred from degenerative back disease.