Aims. To assess how the cost-effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) varies with age, sex, and preoperative Oxford Hip or Knee Score (OHS/OKS); and to identify the patient groups for whom THA/TKA is cost-effective. Methods. We conducted a cost-effectiveness analysis using a Markov model from a United Kingdom NHS perspective, informed by published analyses of patient-level data. We assessed the cost-effectiveness of THA and TKA in adults with hip or knee osteoarthritis compared with having no arthroplasty surgery during the ten-year time horizon. Results. THA and TKA cost < £7,000 per quality-adjusted life-year (QALY) gained at all preoperative scores below the absolute referral thresholds calculated previously (40 for OHS and 41 for OKS). Furthermore, THA cost < £20,000/QALY for patients with OHS of ≤ 45, while TKA was cost-effective for patients with OKS of ≤ 43, since the small improvements in quality of life outweighed the cost of surgery and any subsequent revisions. Probabilistic and one-way sensitivity analyses demonstrated that there is little uncertainty around the conclusions. Conclusion. If society is willing to pay £20,000 per QALY gained, THA and TKA are cost-effective for nearly all patients who currently undergo surgery, including all patients at and above our calculated absolute referral thresholds. Cite this article: Bone Joint J 2020;102-B(7):950–958

Aims. The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes. Patients and Methods. A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years (. sd. 11.6; 14 to 95); mean body mass index (BMI) 28.5 kg/m. 2. (. sd. 5.7; 15 to 72); 1253 female (60%)) and 2168 patients undergoing 2168 TKAs (mean age 69.3 years (. sd. 9.6; 22 to 91); BMI 30.8 kg/m. 2. (. sd. 5.8; 13 to 57); 1244 female (57%)) were recorded. Univariate analysis was used to identify variables associated with an EQ-5D score < 0: age, BMI, sex, deprivation quintile, comorbidities, and joint-specific function measured using the Oxford Hip Score (OHS) or Oxford Knee Score (OKS). Multivariate logistic regression was performed. EQ-5D and OHS/OKS were repeated one year following surgery in 1555 THAs and 1700 TKAs. Results. Preoperatively, 391 THA patients (19%) and 263 TKA patients (12%) were WTD. Multivariate analysis identified preoperative OHS, deprivation, and chronic obstructive pulmonary disease in THA, and OKS, peripheral arterial disease, and inflammatory arthropathy in TKA as independently associated with WTD status (p < 0.05). One year following arthroplasty EQ-5D scores improved significantly (p < 0.001) and WTD rates reduced to 35 (2%) following THA and 53 (3%) following TKA. Patients who were WTD preoperatively achieved significantly (p < 0.001) worse joint-specific Oxford scores and satisfaction rates one year following joint arthroplasty, compared with those not WTD preoperatively. Conclusion. In total, 19% of patients awaiting THA and 12% awaiting TKA for degenerative joint disease are in a health state WTD. Although specific comorbidities contribute to this, hip- or knee-specific function, mainly pain, appear key determinants and can be reliably reversed with an arthroplasty. Cite this article: Bone Joint J 2019;101-B:941–950

Aims. To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores. Methods. Existing UK data from 222,933 knee and 209,760 hip arthroplasty patients were used to model an individual’s probability of gaining meaningful improvement after surgery based on their preoperative Oxford Knee or Hip Score (OKS/OHS). A clinically meaningful improvement after arthroplasty was defined as ≥ 8 point improvement in OHS, and ≥ 7 in OKS. Results. The upper preoperative score threshold, above which patients are unlikely to achieve any meaningful improvement from surgery, is 41 for knees and 40 for hips. At lower scores, the probability of improvement increased towards a maximum of 88% (knee) and 95% for (hips). Conclusion. By our definition of meaningful improvement, patients with preoperative scores above 41 (OKS) and 40 (OHS) should not be routinely referred to secondary care for possible arthroplasty. Using lower thresholds would incrementally increase the probability of meaningful benefit for those referred but will exclude some patients with potential to benefit. The findings are useful to support the complex shared decision-making process in primary care for referral to secondary care; and in secondary care for experienced clinicians counselling patients considering knee or hip arthroplasty, but should not be used in isolation. Cite this article: Bone Joint J 2020;102-B(7):941–949

Aims. We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH). Methods. This retrospective comparative study included 81 patients with ONFH; 37 patients (40 hips) underwent CVO with BIG (BIG group) and 44 patients (47 hips) underwent CVO alone (CVO group). Patients in the BIG group were followed-up for a mean of 12.2 years (10.0 to 16.5). Patients in the CVO group were followed-up for a mean of 14.5 years (10.0 to 21.0). Assessment parameters included the Harris Hip Score (HHS), Oxford Hip Score (OHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), complication rates, and survival rates, with conversion to total hip arthroplasty (THA) and radiological failure as the endpoints. Results. There were no significant differences in preoperative and postoperative HHS or postoperative OHS and JHEQ between the BIG group and the CVO group. Complication rates were comparable between groups. Ten-year survival rates with conversion to THA and radiological failure as the endpoints were not significantly different between groups. Successful CVO (postoperative coverage ratio of more than one-third) exhibited better ten-year survival rates with radiological failure as the endpoint in the BIG group (91.4%) than in the CVO group (77.7%), but this difference was not significant (p = 0.079). Conclusion. Long-term outcomes of CVO with BIG were favourable when proper patient selection and accurate surgery are performed. However, this study did not show improvements in treatment results with the concomitant use of BIG. Cite this article: Bone Joint J 2021;103-B(4):665–671

Aims. The aim of this study was to assess the functional gain achieved following hip resurfacing arthroplasty (HRA). Patients and Methods. A total of 28 patients (23 male, five female; mean age, 56 years (25 to 73)) awaiting Birmingham HRA volunteered for this prospective gait study, with an age-matched control group of 26 healthy adults (16 male, ten female; mean age, 56 years (33 to 84)). The Oxford Hip Score (OHS) and gait analysis using an instrumented treadmill were used preoperatively and more than two years postoperatively to measure the functional change attributable to the intervention. Results. The mean OHS improved significantly from 27 to 46 points (p < 0.001) at a mean of 29 months (12 to 60) after HRA. The mean metal ion levels at a mean 32 months (13 to 60) postoperatively were 1.71 (0.77 to 4.83) µg/l (ppb) and 1.77 (0.68 to 4.16) µg/l (ppb) for cobalt and chromium, respectively. When compared with healthy controls, preoperative patients overloaded the contralateral good hip, limping significantly. After HRA, patients walked at high speeds, with symmetrical gait, statistically indistinguishable from healthy controls over almost all characteristics. The control group could only be distinguished by an increased push-off force at higher speeds, which may reflect the operative approach. Conclusion. Patients undergoing HRA improved their preoperative gait pattern of a significant limp to a symmetrical gait at high speeds and on inclines, almost indistinguishable from normal controls. HRA with an approved device offers substantial functional gains, almost indistinguishable from healthy controls. Cite this article: Bone Joint J 2019;101-B:1423–1430

Aims. To validate the English language Forgotten Joint Score-12 (FJS-12) as a tool to evaluate the outcome of hip and knee arthroplasty in a United Kingdom population. Patients and Methods. All patients undergoing surgery between January and August 2014 were eligible for inclusion. Prospective data were collected from 205 patients undergoing total hip arthroplasty (THA) and 231 patients undergoing total knee arthroplasty (TKA). Outcomes were assessed with the FJS-12 and the Oxford Hip and Knee Scores (OHS, OKS) pre-operatively, then at six and 12 months post-operatively. Internal consistency, convergent validity, effect size, relative validity and ceiling effects were determined. Results. Data for the TKA and THA patients showed high internal consistency for the FJS-12 (Cronbach α = 0.97 in TKAs, 0.98 in THAs). Convergent validity with the Oxford Scores was high (r = 0.85 in TKAs, r = 0.79 for THAs). From six to 12 months, the change was higher for the FJS-12 than for the OHS in THA patients (effect size d = 0.21 versus -0.03). Ceiling effects at one-year follow-up were low for the FJS-12 with just 3.9% (TKA) and 8.8% (THA) of patients achieving the best possible score. Conclusion. The FJS-12 has strong measurement properties in terms of validity, internal consistency and sensitivity to change in TKA and THA patients. Low ceiling effects and good relative validity allow the monitoring of longer term outcomes, particularly in well-performing groups after total joint arthroplasty. Cite this article: Bone Joint J 2017;99-B:218–24

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The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

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Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

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To determine ten-year failure rates following 36 mm metal-on-metal (MoM) Pinnacle total hip arthroplasty (THA), and identify predictors of failure.