There is paucity of reliable data examining the treatment pathway for hip replacements over the life of the patient in terms of risk of revision and re-revisions.

We did a retrospective observational registry-based study of the National Joint Registry, using data on hip replacements from all participating hospitals in England and Wales, UK. We included data on all first revisions, with an identifiable primary procedure, with osteoarthritis as the sole indication for the original primary procedure. Kaplan-Meier estimates were used to determine the cumulative probability of revision and subsequent re-revision after primary hip replacement. Analyses were stratified by age and gender, and the influence of time from first to second revision on the risk of further revision was explored.

Between 2003, and 2019, there were 29 010 revision hip replacements with a linked primary episode. Revision rates of revision hip replacements were higher in patients younger than 55 years than in older age groups. After revision of primary total hip replacement, 21·3% (95% CI 18·6–24·4) of first revisions were revised again within 15 years, 22·3% (20·3–24·4) of second revisions were revised again within 7 years, and 22·3% (18·3–27·0) of third revisions were revised again within 3 years. After revision of hip resurfacing, 23·7% (95% CI 19·6–28·5) of these revisions were revised again within 15 years, 21·0% (17·0–25·8) of second revisions were revised again within 7 years, and 19·3% (11·9–30·4) of third revisions were revised again within 3 years. A shorter time between revision episodes was associated with earlier subsequent revision.

Younger patients are at an increased risk of multiple revisions. Patients who undergo a revision have a steadily increasing risk of further revision the more procedures they undergo, and each subsequent revision lasts for approximately half the time of the previous one.

Accurate cup placement in total hip arthroplasty (THA) for the patients with developmental dysplasia of the hip (DDH) is one of the challenges due to distinctive bone deformity. Robotic-arm assisted system have been developed to improve the accuracy of implant placement. This study aimed to compare the accuracy of robotic-arm assisted (Robo-THA), CT-based navigated (Navi-THA), and manual (M-THA) cup position and orientation in THA for DDH.

A total of 285 patients (335 hips) including 202 M-THAs, 45 Navi-THAs, and 88 Robo-THA were analyzed. The choice of procedure followed the patient's preferences. Horizontal and vertical center of rotation (HCOR and VCOR) were measured for cup position, and radiographic inclination (RI) and anteversion (RA) were measured for cup orientation. The propensity score-matching was performed among three groups to compare the absolute error from the preoperative target position and angle.

Navi-THA showed significantly smaller absolute errors than M-THA in RI (3.6° and 5.4°) and RA (3.8° and 6.0°), however, there were no significant differences between them in HCOR (2.5 mm and 3.0 mm) or VCOR (2.2 mm and 2.6 mm). In contrast, Robo-THA showed significantly smaller absolute errors of cup position than both M-THA and Navi-THA (HCOR: 1.7 mm and 2.9 mm, vs. M-THA, 1.6 mm and 2.5 mm vs. Navi-THA, VCOR:1.7 mm and 2.4 mm, vs. M-THA, 1.4 mm and 2.2 mm vs. Navi-THA). Robo-THA also showed significantly smaller absolute errors of cup orientation than both M-THA and Navi-THA (RI: 1.4° and 5.7°, vs. M-THA, 1.5° and 3.6°, vs. Navi-THA, RA: 1.9° and 5.8° vs. M-THA, 2.1° and 3.8° vs. Navi-THA).

Robotic-arm assisted system showed more accurate cup position and orientation compared to manual and CT-based navigation in THA for DDH. CT-based navigation increased the accuracy of cup orientation compared to manual procedures, but not cup position.

The gold standard treatment of hip dysplasia is a peri-acetabular osteotomy (PAO). Labral tears are seen in the majority of patients presenting with hip dysplasia and diagnosed using Magnetic Resonance Imaging (MRI). The goal was to (1) evaluate utility/value of MRI in patients undergoing hip arthroscopy at time of PAO, and (2) determine whether MRI findings of labral pathology can predict outcome.

A prospective randomized controlled trial was conducted at tertiary institutions, comparing patients with hip dysplasia treated with isolated PAO versus PAO with adjunct hip arthroscopy. This study was a subgroup analysis on 74 patients allocated to PAO and adjunct hip arthroscopy (age 26±8 years; 89.2% females). All patients underwent radiographic and MRI assessment using a 1.5-Tesla with or 3-Tesla MRI without arthrography to detect labral or cartilage pathology. Clinical outcome was assessed using international Hip Outcome Tool-33 (iHOT).

74% of patients (55/74) were pre-operatively diagnosed with a labral tear on MRI. Among these, 41 underwent labral treatment (74%); whilst among those without a labral tear on MRI, 42% underwent labral treatment (8/19). MRI had a high sensitivity (84%), but a low specificity (56%) for labral pathology (p=0.053). There was no difference in pre-operative (31.3±16.0 vs. 37.3±14.9; p=0.123) and post-operative iHOT (77.7±22.2 vs. 75.2±23.5; p=0.676) between patients with and without labral pathology on MRI.

Value of MRI in the diagnostic work-up of a patient with hip dysplasia is limited. MRI had a high sensitivity (84%), but low specificity (44%) to identify labral pathology in patients with hip dysplasia. Consequently, standard clinical MRI had little value as a predictor of outcome with no differences in PROM scores between patients with and without a labral tear on MRI. Treatment of labral pathology in patients with hip dysplasia remains controversial. The results of this subgroup analysis of a prospective, multi-centre RCT do not show improved outcome among patients with dysplasia treated with labral repair.

Satisfactory intermediate and long-term results of rotational acetabular osteotomy (RAO) for the treatment of early osteoarthritis secondary to developmental dysplasia of the hip have been reported. The purpose of this study is to examine the 30-year results of RAO.

Between 1987 and 1994, we treated 49 patients (55 hips) with RAO for diagnosis of pre- OA or early-stage OA. Of those patients, 35 patients (43 hips) were available at a minimum of 28 years. The follow-up rate was 78.2% and the mean follow-up was 30.5 years. The mean age at the time of surgery was 34 years. Clinical evaluation was performed with the Merle d'Aubigne and Postel rating scale, and radiographic analyses included measurements of the center-edge angle, acetabular roof angle, and head lateralization index on preoperative, postoperative AP radiographs of the pelvis. Postoperative joint congruency was classified into four grades. The radiographic evidence of progression of OA was defined as the minimum joint space less than 2.5mm.

The mean preoperative clinical score was 14.0, which improved to a mean of 15.3 at the time of the latest follow-up. The mean center-edge angle improved from 0.6° preoperatively to 34° postoperatively, the mean acetabular roof angle improved from 28.4°preoperatively to 1.0°postoperatively, the mean head lateralization index improved from 0.642 preoperatively to 0.59 postoperatively. Postoperative joint congruency was excellent in 11 hips, good in 29 hips, and fair in 3 hips. Nineteen patients (20 hips) had radiographic OA progression, and 10 patients (11 hips) were converted to THA. Kaplan-Meier survivorship analysis, with radiographic OA progression as the end point, predicted survival of 75.6% at 20 years and 48.8% at 30 years, and with THA conversion as the end point, 90.2% at 20 years and 71.2% at 30 years.

The RAO is an effective surgical procedure for symptomatic dysplastic hips of pre- and early-stage OA and could change the natural history of the dysplastic hip.

Total Hip Arthroplasty (THA) surgery is a physical and cognitive challenge for surgeons. Data on stress levels, cognitive and physical load of orthopaedic surgeons, as well as ergonomic impact, are limited. With and without the use of an automated impaction device, operational efficiency and the surgeon's ergonomic, mental, and physical load was investigated.

In a total of thirty THA procedures, a standard manual technique was compared with an automated impaction device. Three computerized cognitive tasks (Simon, pattern comparison, and pursuit rotor) and five physical tests (isometric wall-sit, plank-to-fatigue, handgrip, supra-postural task, and shoulder endurance) were used to assess psychophysiological load of the surgeon. Surgeon's cortisol concentration was evaluated from saliva samples. Postural risk was assessed by Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Efficiency was assessed by timing surgical steps and instrumentation flow.

Cognitive performances after automated impaction showed faster response times and lower error rates with a greater time-on-target (+1.5 s) and a lower mouse deviation from target (−1.7 pixels). Manual impaction showed higher physical exhaustion in the isometric wall-sit test (10.6% vs. 22.9%), plank-to-fatigue (2.2% vs. 43.8%), the number of taps in the supra-postural task (−0.7% vs. −7.7%), handgrip force production in the dominant (−6.7% vs. −12.7%) and contralateral hand (+4.7% vs. +7.7%), and in shoulder endurance (−15s vs. −56s). An increase of 38.2% in salivary cortisol concentration between the midday (1.31 nmol/l) and afternoon session (1.81 nmol/l) was observed with manual impaction. After using automated impaction, salivary cortisol concentration decreased (−51.2%). Manual broaching time was on average 6′20’’ versus 7’3’’ with automated impaction. RULA of manual impaction scored 6 for cup impaction and 5 for femoral broaching, versus 3 and 3 for automated impaction, respectively. REBA of manual impaction scored 9 for cup impaction and 5 for femoral broaching, versus 4 and 3 for automated impaction, respectively.

Automated impaction lowers surgeons’ cognitive and physical fatigue and leads to reduced stress and improved ergonomics without loss of surgical efficiency.

The periacetabular osteotomy (PAO) is a well-described procedure for symptomatic acetabular dysplasia. For severe acetabular deformities, the efficacy of acetabular reorientation remains controversial and the literature on mid to long-term outcomes is limited. The purpose of this study was to analyze average 10-year clinical and radiographic results of the PAO for severe acetabular dysplasia.

We retrospectively analyzed a consecutive series of patients undergoing PAO for severe acetabular dysplasia as defined by LCEA < 5˚. Patient demographics, radiographic measurements, modified Harris Hip score (MHHS), UCLA activity, SF-12, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed.

Sixty-eight patients (82 hips; 54 females) with an average age 20.7 and BMI of 24.4 kg/m2 were included. Mean follow-up was follow up was 10.3 years. . The LCEA and ACEA improved a mean of 32.8˚ (8.4˚ to 24.4˚, p<0.0001) and 31.6˚ (−4.9˚ to 26.7˚, p< 0.0001), respectively. MHHS improved an average of 17.5 points (64.6 to 82.3, p<0.0001), WOMAC Pain subscore improved an average of 21.1 points (65.7 to 85.0, p = 0.004), and SF-12 physical improved 11.8 points (from 40.3 to 50.6, p = 0.006). Activity improved as indicated by a 1.5-point increase in the UCLA Activity score (6.4 to 7.9, p=0.005). Six hips (9.1%) converted to THA at average 6.8 years post-PAO. Kaplan-Meier survival analysis with THA as the endpoint was 92% at 15 years (95% confidence interval [CI] (81%–96%). Multivariable linear regression analysis revealed concurrent osteochondroplasty was associated with a decreased risk of PAO failure.

PAO is an effective treatment for severe acetabular dysplasia. At average 10.3 years, clinical and radiographic outcomes demonstrate pain relief, improved hip function, and major deformity correction. We observed minimal clinical deterioration over time.

Simulation use in training is rapidly becoming a mainstay educational tool seen to offer perceived benefits of a safe environment for repeated practice and learning from errors without jeopardising patient safety. However, there is currently little evidence addressing the trainees’ perspectives and attitudes of simulation training, particularly in comparison with trainers and the educational community.

This study investigates orthopaedic trainees’ and trainers’ conceptions of learning from simulation-based training, exploring whether the orthopaedic community are ‘on the same page’, with respect to each other and the educational community. Qualitative research in the form of semi-structured interviews is used to identify commonalities and differences between trainee and trainer conceptions, based on respective experiences and expectations, and suggests ways of enhancing collaboration between stakeholders to achieve better alignment of conceptions.

The research revealed that orthopaedic trainees and trainers conceive key themes in a similar manner: supporting the role of simulation in developing the ‘pre-trained novice’ as opposed to skill refinement or maintenance; attributing greater importance to non-technical rather than technical skills development using simulation; questioning the transferability to practice of learnt skills; and emphasising similar barriers to increased curriculum integration, including financing and scheduling. These conceptions are largely in contrast to those of the educational community, possibly due to differing conceptions of learning between the two communities, along with a lack of a common language in the discourse of simulation.

There was some evidence of changing attitudes and positively emerging conceptions among the orthopaedic community, and capitalising on this by engaging trainers and trainees may help reconcile the differing conceptions and facilitate increasing simulation utilisation and curriculum integration. Developing a common language to make the educational more tangible to surgeons, bringing the educational closer to the surgical, may help maximise the educational benefit and shape the future of simulation use in surgical training.

Rotational acetabular osteotomy (RAO), one of periacetabular osteotomies, is an effective joint-preserving surgical treatment for developmental dysplasia of the hip. Since 2013, we have been using a CT-based navigation for RAO to perform safe and accurate osteotomy. CT-based navigation allows precise osteotomy during surgery but cannot track the bony fragment after osteotomy. Thus, it is an issue to achieve successful reorientation in accordance with preoperative planning. In this presentation, we introduce a new method to achieve reorientation and evaluate its accuracy.

Thirty joints in which CT-based navigated RAO was performed were included in this study. For the first 20 joints, reorientation was confirmed by tracing the lateral aspect of rotated fragment with navigation and checked if it matched with the preoperative planning. For the latter 10 joints, a new method was adopted. Four fiducial points were made on lateral side of the acetabulum in the preoperative 3-dimensional model and intraoperatively, rotation of the osteotomized bone was performed so that the 4 fiducial points match the preoperative plan.

To assess the accuracy of position of rotated fragment in each group, preoperative planning and postoperative CT were compared. A total of 24 radial reformat images of postoperative CT were obtained at a half-hour interval following the clockface system around the acetabulum. In every radial image, femoral head coverage of actual postop- and planned were measured to evaluate the accuracy of acetabular fragment repositioning.

The 4-fiducial method significantly reduced the reorientation error. Especially in the 12:00 to 1:00 position of the acetabulum, there were significantly fewer errors (p<0.01) and fewer cases with under-correction of the lateral acetabular coverage.

With the new method with 4 reference fiducials, reorientation of the acetabulum could be obtained as planned with lesser errors.

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). DAA THA is increasing, particularly among surgeons who have learned the technique during overseas fellowships. Whether DAA offers long-term clinical benefit is unclear.

We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multi-centre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10-year Oxford Hip Score (OHS) and 10-year revision rates.

125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10-year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value <0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point post-op the OHS for DAA THA was 42.63, 42.10 for posterior THA and the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point.

Whilst there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistically significant difference between the outcome measures or revision rates for the two approaches.

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocations. This study investigates those at risk for recurrent dislocation after revision THA for instability at a single institution.

Between 2009 and 2019, 163 patients underwent revision THA for instability at a single institution. Thirty-three of these patients required re-revision THA due to recurrent dislocation. Cox proportional hazard models with death as a competing event were used to analyze risk factors, including prosthesis sizing and alignment. Paired t-tests or Wilcoxon signed rank tests were used to assess patient outcomes (Veterans RAND 12 (VR-12) physical score, VR-12 mental score, Harris Hip Score, and hip disability and osteoarthritis outcome score for joint replacement).

Duration of follow-up until either re-revision or final follow-up was a mean of 45.3 ± 38.2 months. The 1-year cumulative incidence for recurrent dislocation after revision was 8.7%, which increased to 19.6% at 5 years and 32.9% at 10 years postoperatively. In the multivariable analysis, high ASA score [HR 2.71], being underweight (BMI<18 kg/m²) [HR 36.26] or overweight/obese (BMI>25 kg/m²) [HR 4.31], use of specialized liners [HR 5.51–10.71], lumbopelvic stiffness [HR 6.29], and postoperative abductor weakness [HR 7.20] were significant risk factors for recurrent dislocation. Increasing the cup size decreased the dislocation risk [HR 0.89]. The dual mobility construct did not affect the risk for recurrent dislocation in univariate or multivariable analyses. VR-12 physical and HHS (pain and function) scores improved postoperatively at midterm.

Patients requiring revision THA for instability are at risk for recurrent dislocation. Higher ASA scores, abnormal BMI, use of special liners, lumbopelvic stiffness, and postoperative abductor weakness are significant risk factors for re-dislocation.

Femoral stem design affects periprosthetic bone mineral density (BMD), which may impact long term survival of cementless implants in total hip arthroplasty (THA). The aim of this study was to examine proximal femoral BMD in three morphologically different uncemented femoral stems designs to investigate whether one particular design resulted in improved preservation of BMD.

119 patients were randomized to receive either a proximally coated dual taper wedge stem, a proximally coated anatomic stem or a fully coated collarless triple tapered stem. Dual energy x-ray absorptiometry scans (Lunar iDXA, GE Healthcare, Madison, WI) assessed BMD across the seven Gruen zones pre-operatively, and post-operatively at 6-weeks, 1-year, and 2-years comparing the unoperated contralateral femur as a control.

BMD increased in zones one (2.5%), two (17.1%), three (13.0%), five (10%) and six (17.9%) for all stems. Greater preservation of BMD was measured on the lateral cortex (zone 2) for both the dual taper wedge and anatomic stems (p = 0.019). The dual taper wedge stem also demonstrated preservation of BMD in the medial calcar (zone 7) whilst the anatomic and triple taper stem declined in this region, however this was not statistically significant (p = 0.059). BMD decreased on average by 2.1% in the mid-diaphysis region, distal to the stem tip (zone 4) for all implants. All stems performed equivalently at final follow-up in all patient reported outcome measures.

Implant design was shown to impact BMD changes. All stems preserved bone at the metaphyseal level in early follow-up, which theoretically indicates favorable implant fixation. There was no significant stress shielding observed, however longer follow-up is required to elucidate the impact of this finding on implant survivorship.

Periprosthetic femoral fracture (PFF) following primary total hip arthroplasty (THA) is of raising concern with the aging of the population. The aim of this retrospective study was to assess the incidence of early PFF associated with Charnley- Kerboull (CK) stems cemented line-to-line according to the “French paradox” principles through the anterior approach (AA) in patients older than 70 years old.

This monocentric study involved 25 surgeons with various level of experience. From a prospectively collected database, all CK stems (AmisK®, Medacta, Castel San Pietro, Switzerland) done consecutively from January 2018 to May 2022 through the AA in patients older than 70 years were included. The measured parameters included canal flare index (CFI), morphological cortical index (MCI), canal-calcar ratio (CCR), ilium-ischial ratio (IIR), ilium overhang, and anterior superior iliac spine (ASIS) to greater trochanter distance. Dorr classification was also recorded.

A total of 416 CK stems performed by 25 surgeons were included. All patients had a minimal 3-month follow-up. The mean age was 77.4 years, and the mean BMI was 25.3 kg/m². According to the Dorr classification 240 hips were of Dorr type A, 144 Dorr type B, and 2 Dorr type C. Mean CFI, MCI, CCR, IIR and ASIS-GT were 3.8, 0.5, 2.8, 2.5, and 101mm, respectively. Amongst the 416 THAs, one (0.24%; 95% CI 0.20 – 0.28%) early PFF Vancouver type B2 fracture that occurred 24 days postoperatively was observed.

This study demonstrated that CK stems cemented according to the “French Paradox” were associated with an extremely low rate of early PFF in patients over 70 years. The observed results are better than those reported with uncemented or taper slip cemented stems. Longer follow-up is warranted to evaluate further rate of fracture that may occur during the bone remodeling process around the femoral component.

Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11).

In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation.

A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database.

In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%.

In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system.

The increased torque required to dislocate dual mobility (DM) components may increase peri-prosthetic femoral fracture (PPF) risk. Current literature often relies on revision as an endpoint and may underestimate PPF. This study aims to review PPF rate, risks and treatment following primary DM implantation.

Prospective cohort study of 549 patients following primary DM total hip arthroplasty (THA) between 2013 and 2021. Collected data included demographics, indication for surgery, cortical index and PPF.

549 patients were identified with primary DM THA. Mean age was 73 years (26–96). 446 (81.2%) patients had their index surgery following hip fracture. 18 patients (3.27%) sustained a PPF. Cumulative PPF rate was 1.5% at 1-year, 2.2% at 5-years and 3.27% overall. PPF was higher in patients undergoing surgery following hip fracture (4%) vs. other indications (1%). OR 4.04 (95% CI:0.53, 30.72), p=0.219. Mean cortical index was lower in patients with PPF 0.4 (95% CI:0.36, 0.45) compared to those without 0.46 (95% CI:0.45, 0.46) p=0.029. Treatment for PPF included 10 (55.6%) open reduction internal fixation (ORIF), 7 (38.9%) revision THA and 1 conservatively managed.

PPF rate following DM use is higher in our cohort than published rates. Our rates are comparable to some papers when subgroup analysis of older patients and cemented taper slip stems are considered. PPF risk with DM may be increased in patients undergoing surgery after hip fracture or with a lower cortical index preoperatively. Over half of PPF were managed with ORIF and may mask PPF risk studies that report using revision as an endpoint.

Femoroacetabular Impingement (FAI) syndrome, characterised by abnormal hip contact causing symptoms and osteoarthritis, is measured using the International Hip Outcome Tool (iHOT). This study uses machine learning to predict patient outcomes post-treatment for FAI, focusing on achieving a minimally clinically important difference (MCID) at 52 weeks.

A retrospective analysis of 6133 patients from the NAHR who underwent hip arthroscopic treatment for FAI between November 2013 and March 2022 was conducted. MCID was defined as half a standard deviation (13.61) from the mean change in iHOT score at 12 months. SKLearn Maximum Absolute Scaler and Logistic Regression were applied to predict achieving MCID, using baseline and 6-month follow-up data. The model's performance was evaluated by accuracy, area under the curve, and recall, using pre-operative and up to 6-month postoperative variables.

A total of 23.1% (1422) of patients completed both baseline and 1-year follow-up iHOT surveys. The best results were obtained using both pre and postoperative variables. The machine learning model achieved 88.1% balanced accuracy, 89.6% recall, and 92.3% AUC. Sensitivity was 83.7% and specificity 93.5%. Key variables determining outcomes included MCID achievement at 6 months, baseline iHOT score, 6-month iHOT scores for pain, and difficulty in walking or using stairs.

The study confirmed the utility of machine learning in predicting long-term outcomes following arthroscopic treatment for FAI. MCID, based on the iHOT 12 tools, indicates meaningful clinical changes. Machine learning demonstrated high accuracy and recall in distinguishing between patients achieving MCID and those who did not. This approach could help early identification of patients at risk of not meeting the MCID threshold one year after treatment.

In this study, we examined the impact of dual-mobility (DM) versus fixed-bearing (FB) implants on outcomes following total hip arthroplasty (THA), a common and successful operation. We examined all-cause revision, revision due to dislocation, postoperative complications and functional scores in patients undergoing primary and revision THA.

A systematic review was performed according to PRISMA guidelines, and was registered in PROSPERO (ID CRD42023403736). The Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus were searched from inception to 12th March 2023. Eligible studies underwent meta-analysis and methodological assessment using the ROBINS-I tool. Data were pooled using a random-effects maximum-likelihood model.

Eight comparative, non-randomised studies involving 2,810 DM implants and 3,188 FB implants were included. In primary THA, the difference in all-cause revision was imprecise (OR 0.82, 95% CI 0.25–2.72), whilst the DM cohort had a statistically significant benefit in revision due to dislocation (OR 0.08, 95% CI 0.02–0.28). In revision THA, the DM cohort showed significant benefit in all-cause revision (OR 0.57, 95% CI 0.31–1.05) and revision due to dislocation (OR 0.14, 95% CI 0.04–0.53). DM implants were associated with a lower incidence of implant dislocation and infection. Functional outcome analysis was limited due to underreporting. No intraprosthetic dislocations were observed.

The results suggest that contemporary DM designs may be advantageous in reducing the risk of all-cause revision, revision due to dislocation, and postoperative complication incidence at mid-term follow-up. Further high-quality prospective studies are needed to evaluate the long-term performance of this design, especially in revision cases.

Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England.

Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs.

In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1.

Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology.

For any figures or tables, please contact the authors directly.

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385).

The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development.

This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.

Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients.

This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures.

Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8.

This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options.

This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip replacement for aseptic loosening.

We conducted a cohort study of first-time, single-stage revision hip replacements (RHR) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome.

Among 12,676 RHR there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant's first RHR (Hazard Ratio (HR) 1·58 (95%CI 1·16 to 2·15)) and remained significantly elevated for their first 26 cases (HR 1·26 (95%CI 1·00 to 1·58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1·28 (95%CI 1·00 to 1·64)) and 80% greater risk of 90-day mortality (HR 1·81 (95%CI 1·02 to 3·21)) compared to volumes of 20/year. RHR performed at hospitals which had cumulatively undertaken fewer than 168 RHR were at up to 70% greater risk of re-revision (HR 1·70 (95% CI 1·12 to 2·60)), and those having undertaken fewer than 309 RHR were at up to three times greater risk of 90-day mortality (HR 3·06 (95% CI 1·19 to 7·86)).

This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHR for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralisation of such cases towards higher-volume units and surgeons.

The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation.

With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key.

This study assesses the validity of the NHFS in predicting mortality after fragility DFFs.

A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases.

Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded.

All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT.

Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk.

285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes.

30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively.

Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714).

The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF.

The number of revision total hip arthroplasties (THA) is increasing. This procedure is associated with a higher complication rate than primary THA, and so it is important for patients to have realistic expectations. The aim of this systematic review was to gather and summarise the available evidence on patients’ expectations following revision THA.

A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar and Web of Science from inception to December 2021. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies.

The search strategy generated 3132 references of which 4 articles met the inclusion criteria. Methodological quality scores ranged from 7–10. Patients have high expectations concerning future walking ability, pain and implant longevity. Implant longevity expectations vary according to the longevity of the primary implant. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction (r = .46 – .47). Only one study assessed fulfilment of patient expectations. Great variability was seen in operationalisation and assessment of expectations.

Patients undergoing revision THA appear to have high expectations with regards to future outcomes. Whilst results are promising, there is a paucity of high-quality data in this area. Further research is needed, which places emphasis on developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools.

Although total hip arthroplasty (THA) is beneficial for many patients with hip osteoarthritis (OA), a subset of patients experience minimal benefit. It is therefore pertinent to understand the predictors of poor functional outcome to facilitate shared decision making. One such predictor is preoperative radiographic OA severity. The aim of this systematic review was to determine whether preoperative radiographic OA severity could predict postoperative patient-reported outcome measures (PROMs) and satisfaction rates after THA.

This systematic review was conducted according to PRISMA guidelines, and the protocol published in PROSPERO (ID:Â CRD42023445918). A literature search was performed using Embase, MEDLINE and Cochrane Library databases. Demographics, radiographic OA severity, PROMs, satisfaction, and complications after THA were collected. A meta-analysis was performed, where appropriate, using a random-effects model.

Of 631 identified articles, 12 were included in the final analysis (8,034 participants; mean age 65.2, 38.1% male, mean BMI 29.1 kg/m2). There were three key findings. Firstly, those with mild OA are less likely to achieve a meaningful clinical improvement in PROMs (odds ratio (OR) 0.50, 95% confidence interval (CI) 0.38, 0.65; p < 0.00001). Secondly, two studies indicates that postoperative patient satisfaction was lower in participants with mild OA. Thirdly, participants with mild arthritis experience less improvement in SF-36 physical functioning (mean difference (MD) -8.31, 95% CI -10.97, -5.64; p < 0.00001) and role physical (MD -5.59, 95% CI -8.40, -2.77; p < 0.0001), but showed higher improvement in general health (MD 1.68, 95% CI 0.31, 3.06; p = 0.02).

Patients with mild OA, as determined radiographically, are less likely to achieve meaningful clinical improvements in PROMs and have lower postoperative satisfaction after THA. This information will improve collaborative decision-making in the preoperative period.

Aims

The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate.

Aims

The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR.

Aims

The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.

Aims

We assessed the long-term outcomes of a large cohort of patients who have undergone a periacetabular osteotomy (PAO), and sought to validate a patient satisfaction questionnaire for use in a PAO cohort.

Aims

The objective of this study was to compare the two-year migration and clinical outcomes of a new cementless hydroxyapatite (HA)-coated titanium acetabular shell with its previous version, which shared the same geometrical design but a different manufacturing process for applying the titanium surface.

Aims

The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA).

Aims

The Birmingham Hip Resurfacing (BHR) arthroplasty has been used as a surgical treatment of coxarthrosis since 1997. We present 20-year results of 234 consecutive BHRs performed in our unit.

Aims

Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients.

Aims

Although the Fitmore Hip Stem has been on the market for almost 15 years, it is still not well documented in randomized controlled trials. This study compares the Fitmore stem with the CementLeSs (CLS) in several different clinical and radiological aspects. The hypothesis is that there will be no difference in outcome between stems.

Aims

This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

Aims

Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients.

Aims

Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery’s outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis.

Aims

Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.

Aims

To evaluate how abnormal proximal femoral anatomy affects different femoral version measurements in young patients with hip pain.

Aims

Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD.

Aims

In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.

Aims

This study aimed to develop and validate a fully automated system that quantifies proximal femoral bone mineral density (BMD) from CT images.

Aims

The aim of this study was to identify the optimal lip position for total hip arthroplasties (THAs) using a lipped liner. There is a lack of consensus on the optimal position, with substantial variability in surgeon practice.

Aims

It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA.

The Canadian Cardiovascular Society (CCS) recommends performing daily troponin testing on postoperative days 0 through 3 for noncardiac surgical patients to decrease the mortality rate due to myocardial injury. Indications for testing include:

->65 yo

-45-64 yo with significant cardiovascular disease

-a Revised Cardiac Risk Index score (RCRI) > 1

Troponin elevation > 30 ng/L is termed “myocardial injury after noncardiac surgery” (MINS).

The study objective was to determine the prognostic relevance of applying CCS recommendations.

669 patients undergoing THA were included in the study. Based on the CCS recommendation there were 4 patient Groups depending on whether or not they met the MINS screening protocol criteria and whether or not it was applied:

-A - met & applied (n=181)

-B - met & not applied (n=248)

-C – not met & applied (n=10)

-D – not met & not applied (n=230)

307 (45.8%) males and 363 (54.2%) females with an average age of 67.8 years were included. Group A- 24% incidence (43 patients) of troponin rise & 5% incidence (9 patients) of cardiac complications. Group B- 0.4% incidence (1 patient) of cardiac complications.

Groups A + B – representing all patients who should have had the MINS screening protocol applied according to the CCS recommendations − 10 (2.3%) patients developed cardiac complication and one (0.2%) patient death

MINS screening protocol group (A & C) LOS was 4.0 days compared to 1.4 days for those not screened (p-value: <0.001).

Applying the CCS MINS screening protocol to elective THA patients added no benefit in predicting/preventing postoperative cardiac events but was associated with a significant increase in LOS. Following current CCS recommendations without more specifications and clinical evidence is unwarranted.

Successful estimation of postoperative PROMs prior to a joint replacement surgery is important in deciding the best treatment option for a patient. However, estimation of the outcome is associated with substantial noise around individual prediction. Here, we test whether a classifier neural network can be used to simultaneously estimate postoperative PROMs and uncertainty better than current methods.

We perform Oxford hip score (OHS) estimation using data collected by the NJR from 249,634 hip replacement surgeries performed from 2009 to 2018. The root mean square error (RMSE) of the various methods are compared to the standard deviation of outcome change distribution to measure the proportion of the total outcome variability that the model can capture. The area under the curve (AUC) for the probability of the change score being above a certain threshold was also plotted.

The proposed classifier NN had a better or equivalent RMSE than all other currently used models. The threshold AUC shows similar results for all methods close to a change score of 20 but demonstrates better accuracy of the classifier neural network close to 0 change and greater than 30 change, showing that the full probability distribution performed by the classifier neural network resulted in a significant improvement in estimating the upper and lower quantiles of the change score probability distribution. Consequently, probabilistic estimation as performed by the classifier NN is the most adequate approach to this problem, since the final score has an important component of uncertainty.

This study shows the importance of uncertainty estimation to accompany postoperative PROMs prediction and presents a clinically-meaningful method for personalised outcome that includes such uncertainty estimation.

In 1975, Sweden started registering primary knee replacement surgeries based on the personal identity number. Individual-based registrations of primary total hip replacements started in 1992 and for hemiarthroplasties the registration started in 2006. The completeness of these registrations is estimated at 98% during the last 10-year period. The long history and high completeness allow for accurate calculations of population-based prevalence of joint replacement and trends over time.

We used all data on primary joint replacements available in the Swedish Arthroplasty Register. The prevalence was calculated using number of alive patients with 1) at least one joint replacement 2) at least one hip replacement 3) at least one knee replacement at the end of each year from 2010 – 2021. Publicly available population numbers were retrieved from Statistics Sweden. We calculated total prevalence and prevalence per age in years.

By the end of 2021, 3.2% of the Swedish population had at least one hip or knee replacement. This was an increase from 2.5% in 2010. Among 80-year-old, the prevalence was 17.5% for any joint replacement. For both hip and knee replacement and all ages, the prevalence was higher for women. For knee replacement, the 2021 prevalence peaked at the age of 89 (9,4%) while the prevalence continuously increased with age for hip replacements.

A considerable proportion of the Swedish elderly population is living with at least one hip or knee replacement. The prevalence has increased during the last 12-year period for both hips and knees. An increasing prevalence may also affect the incidence of fractures and infections. Knowledge about the prevalence is fundamental for planning future demand for primary and revision hip and knee replacement.

There is a surge of patients on the waiting-list for primary total hip replacement (THR), due to unprecedented reduction of elective activity caused by COVID-19. A higher incidence of femoral head collapse (FC) and acetabular erosion (AE) leading to increase in pain and instability as well as requirement of more complex surgery and potentially higher risk to patients was noted in this period. Rapidly progressive Arthritis (RPA) of the hip is a known entity often described as progression of joint space narrowing greater than 2mm over one year time period. The study aims to identify any potential relationship between waiting time and establishment of femoral head collapse and/ or acetabular erosion.

A retrospective review of arthroplasty surgeon's waiting list during COVID. Serial hip radiographs recorded between February 2020 and February 2022 were analysed.

FC was quantified as a percentage of the femoral head radius, while AE was assessed by drawing two parallel lines, one through both tear drops and the other through superior most aspect of intact acetabulum, parallel to the inter tear-drop line and expressed as percentage of normal side.

Only 105 patients out of 264 patients added to the waiting list had elective arthroplasty for hip/knee. Only 35 patients out of 90 listed for THR, had the surgery.

36 of 90 (40%) were found to have developed FC and fitted the criteria for RPA. Acetabular erosion was seen in 19 (21%). Therefore 53% (19 of 36) of those who developed FC progressed to AE.

Incidence of collapse was higher in females (32%), with mean age of 62 (range 51–81), compared to 21% in males with mean age 59 (range 53–87). Mean extent of femoral head collapse was 20% (10 – 44%).

A significant proportion of patients added to waiting list during COVID developed RPA of the hip with 40% having femoral head collapse and 21% progressing to acetabular erosion leading to a complex case-mix. Patients on long waiting lists need regular x-ray checks/PROMS since significant proportion progress to FC and Acetabular Erosion.

Hip fracture represents a significant challenge, placing increasing pressure on health and social care services in Scotland. This study establishes the ‘historic’ hip fracture burden, namely, the annual number of hip fractures in Scotland, and respective incidence, between 2017 – 2021. Furthermore, the ‘projected’ hip fracture burden and incidence from 2022 – 2029 was estimated, to inform future capacity and funding of health and social care services.

The number of individuals with a hip fracture in Scotland between 2017 and 2021 was identified through the Scottish Hip Fracture Audit, enabling the annual number of hip fractures and respective incidence between 2017 – 2021 to be calculated. Projection modelling was performed using Exponential Smoothing and Auto Regressive Integrated Moving Average to estimate the number of hip fractures occurring annually from 2022 – 2029. A combined average projection was employed to provide a more accurate forecast. Accounting for predicted changes within the population demographics of Scotland, the projected hip fracture incidence up to 2029 was calculated.

Between 2017 and 2021 the annual number of hip fractures in Scotland increased from 6675 to 7797 (15%), with an increase in incidence from 313 to 350 per 100,000 (11%) of the at-risk population. Hip fracture was observed to increase across all groups, notably males, and the 70–79 and 80–89 age cohorts. By 2029, the combined average projection estimated the annual number of hip fractures at 10311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. The largest percentage increase in hip fracture by 2029 occurs in the 70–79 and 80–89 age cohorts (57% and 53% respectively). Based upon these projections, overall length of hospital stay following hip fracture will increase by 60699 days per annum by 2029, incurring an additional cost of at least £25 million.

Projection modelling demonstrates the annual number of hip fractures in Scotland will increase substantially by 2029, with significant implications for health and social care services. This increase in hip fracture burden and incidence is influenced strongly by changing population demographics, primarily an ageing population.

Primary total hip replacement (THR) is a successful and common operation which orthopaedic trainees must demonstrate competence in prior to completion of training. This study aimed to determine the impact of operating surgeon grade and level of supervision on the incidence of 1-year patient mortality and all-cause revision following elective primary THR in a large UK training centre.

National Joint Registry (NJR) data for all elective primary THR performed in a single University Teaching Hospital from 2005–2020 were used, with analysis performed on the 15-year dataset divided into 5-year temporal periods (B1 2005–2010, B2 2010–2015, B3 2015–2020). Outcome measures were mortality and revision surgery at one year, in relation to lead surgeon grade, and level of supervision for trainee-led operations.

9999 eligible primary THR were undertaken, of which 5526 (55.3%) were consultant led (CL), and 4473 (44.7%) trainees led (TL). Of TL, 2404 (53.7%) were non-consultant supervised (TU), and 2069 (46.3%) consultant supervised (TS). The incidence of 1-year patient mortality was 2.05% (n=205), and all-cause revision was 1.11% (n=111). There was no difference in 1-year mortality between TL (n=82, 1.8%) and CL (n=123, 2.2%) operations (p=0.20, OR 0.78, CI 0.55–1.10). The incidence of 1-year revision was not different for TL (n=56, 1.3%) and CL (n=55, 1.0%) operations (p=0.15, OR 1.37, CI 0.89–2.09). Overall, there was no temporal change for either outcome measure between TL or CL operations. A significant increase in revision within 1-year was observed in B3 between TU (n=17, 2.7%) compared to CL (n=17, 1.0%) operations (p=0.005, OR 2.81, CI 1.35–5.87).

We found no difference in 1-year mortality or 1-year all-cause revision rate between trainee-led primary THR and consultant-led operations over the entire fifteen-year period. However, unsupervised trainee led THR in the most recent 5-year block (2015–2020) has a significantly increased risk of early revision, mainly due to instability and prosthetic joint infection. This suggests that modern surgical training is having a detrimental effect on THR patient outcomes. More research is needed to understand the reasons if this trend is to be reversed.

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.

We sought to determine the short to medium-term clinical and radiographic outcomes using a short stem in young adults with a proximal femoral deformity (PFD).

We prospectively studied 31 patients (35 hips) with PFDs treated with an uncemented primary THA using a short stem with cervicometaphyseal fixation between 2011–2018. There were 19 male (23 hips) and 12 female (12 hips) patients, with a mean BMI of 26.7±4.1 kg/m². Twelve cases had a previous surgical procedure, and six of them were failed childhood osteotomies. Mean age of the series was 44±12 years, mean follow-up was 81±27 months and no patients were lost to follow-up. PFDs were categorized according to a modified Berry´s classification. Average preoperative leg-length discrepancy (LLD) was −16.3 mm (−50 to 2).

At a mean time of 81 months of follow-up, survival rate was 97% taking revision of the stem for any reason and 100% for aseptic loosening as endpoints. No additional femoral osteotomy was required in any case. Average surgical time was 66 minutes (45 to 100). There was a significant improvement in the mHHS score when comparing preoperative and postoperative values (47.3±10.6 vs. 92.3±3.7, p=0.0001). Postoperative LLD was in average 1 mm (−9 to 18) (p=0.0001). According to Engh's criteria, all stems were classified as stable without signs of loosening. Postoperative complications included 1 pulmonary embolism, 1 neurogenic sciatic pain, 1 transient sciatic nerve palsy that recovered completely after six months, and 2 acute periprosthetic joint infections. One patient suffered a Vancouver B2 periprosthetic femoral fracture 45 days after surgery and was revised with a modular distally fixed uncemented fluted stem.

A type 2B short stem evidenced promising outcomes at short to medium-term follow up in young adult patients with PFDs, avoiding the need for corrective osteotomies and a revision stem.

The benefit of dual mobility cup (DMC) for primary total hip arthroplasties (THA) is still controversial. This study aimed to compare 1) the complications rate, 2) the revisions rate, 3) the survival rate after monobloc DMC compared to large femoral heads (LFH) in primary THA.

Between 2010 and 2019, 2,075 primary THA using cementless DMC or LFH were included. Indications for DMC were patients older than 70 years old or with high risk of dislocation. Every other patient received a LFH. Exclusion criteria were cemented implants, femoral neck fracture, a follow-up of less than one year. 1,940 THA were analyzed: 1,149 DMC (59.2%), 791 LFH (40.8%). The mean age was 73 ±9.2 years old in DMC group and 57 ±12 in LFH group. The complications and the revisions have been assessed retrospectively.

The mean follow-up was 41.9 months ±14 [12–134]. There were significantly fewer dislocations in DMC group (n=2; 0.17%) compared to LFH group (n=8; 1%) (p=0.019). The femoral head size had no impact on the dislocations rate in LFH group (p=0.70). The overall complication rate in DMC (n=59; 5.1%) and LFH (n=53; 6.7%) were not statistically different (p=0.21). No specific complication was attributed to the DMC. In DMC group, 18 THA (1.6%) were revised versus 15 THA in LFH group (1.9%) (p= 0.71). There was no statistical difference for any cause of revisions in both groups. The cup aseptic revision-free survival rates at 5 years were 98% in DMC group and 97.3% in LFH group (p=0.78).

Monobloc DMC had a lower risk of dislocation in a high-risk population than LFH in a low-risk population at the mid-term follow-up. There was no significant risk of specific complications or revisions for DMC in a large cohort. Monobloc DMC can be safely used in a selected high-risk population.

Modular dual mobility (DM) articulations are increasingly utilized during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) abnormalities with serum metal ion levels in patients with DM articulations.

All patients with an asymptomatic, primary THA and DM articulation with >2-year follow-up underwent MARS-MRI of the operative hip. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels.

Forty-five patients (50 hips) with a modular DM articulation were included with average follow-up of 3.7±1.2 years. Two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels >3.0 μg/L. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/L. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels <1.0 μg/L, while one (2.6%) had a cobalt level of 1.4 μg/L. One patient (2.2%) had a chromium level >3.0 μg/L and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels >5.0 μg/L without associated MARS-MRI abnormalities.

Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic dual mobility articulations occur infrequently (4.4%), but further assessment of these patients is necessary.

Level of Evidence: Level IV

Total hip arthroplasty has been constantly evolving with technological improvements to achieve the best survival rates. Although the new implants are under closer surveillance through processes such as Beyond Compliance, orthopaedic surgeons generally tend to look out for the latest implants with good short-term results and hope for better long-term results for these. We questioned whether such an assumption or bias is valid.

We analysed the data of Kaplan-Meier estimates of cumulative revisions of primary hip replacement by fixation, stem/cup brand and bearing combinations from the NJR 19th Annual Report published in September 2022. We performed a univariate linear regression analysis to predict the 10- and 15-year revision rates for these different hip implant combinations from the 3- and 5-year revision rates.

Thirty-seven implant combinations had their 15-year revision rates reported and 67 had the 10-year revision rates. The correlation co-efficients were 0.43 and 0.58 for the 3-year and 5-year revision rates against 15-year revision rates. Only 17% of the variance in 15-year revision rates could be predicted by a linear regression model from the 3-year revision rate and 32% from the 5-year revision rate. Corresponding values for the 10-year revision rates were 46% and 67%.

95% prediction intervals for the 15-year revision rate were +/− 3.1% from the 3-year revision rate and +/− 2.8% from the 5-year revision rate. Corresponding values for the 10-year revision rates were +/− 1.3% and +/− 1%.

19 of 37 implant combinations showed 15-year revision rate of more than 4%. Average 3-year and 5-year revision rates for this cohort was 1.0% and 1.42% compared to 1.4% and 1.9% for the rest and the difference was statistically significant.

Although average early revision rates showed small but significant difference between the groups with lower and higher 15-year revision rates, the prediction intervals for 15-year revision rates for individual hips based on their 3-year and 5-year revision rates are very wide. Three- and 5-year revision rates for primary total hip replacements are poor predictors of 15-year revision rates.

Subsidence remains a concern when utilizing modern tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability and failure to obtain stem osseointegration. This study aims to compare stem subsidence across three modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or ‘scratch fit’ on subsidence, as well as the role of intraoperative imaging in maximizing this bicortical contact and preventing stem subsidence.

A retrospective review of 271 hip arthroplasties utilizing modern TFT stems in a single institution was performed. Three stem designs were included in the analysis: one monoblock TFT stem (n=91) and two modular TFT stems (Modular A [n=90]; Modular B [n=90]). Patient demographics, Paprosky femoral bone loss classification, bi-cortical contact, utilization of intra-operative imaging and stem subsidence (comparison of initial post-operative radiograph to the latest follow up radiograph - minimum three months) were recorded.

There was no statistically significant difference in the amount of subsidence between the three stems (Monoblock: 2.33mm, Modular A: 3.43mm, Modular B: 3.02mm; p=0.191). There was no statistical difference in subsidence >5mm between stems (Monoblock: 9.9%, Modular A: 22.2%, Modular B: 16.7%). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was strongly associated with reduced subsidence (p=0.004). Intra-operative imaging was used in 46.5% (126/271) of cases; this was not correlated with bicortical contact (p=0.673) or subsidence (p=0.521). Across all groups, only two stems were revised for subsidence (0.7%).

All three modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate.

The current evidence favors replacement for the treatment of displaced femoral neck fractures in the older patients. Controversies remain whether total hip replacement (THR), or hemiarthroplasty (HA) would result in better outcomes. The purpose of this study is to compare the outcomes, and the complications in patients who underwent THR or HA for displaced femoral neck fractures.

There were 345 consecutive patients who had undergone either a THR or HA at a single institution. THR was done in 137, and HA was done in 208 patients, respectively. Standard peri-operative data were collected.

The mean values for the data in the THR group are: age 69 years, ASA 2.7, OR time was 99 minutes, estimated blood loss 354 ml, and the length of stay 8 days. The mean values for the data in the HA group are: age 75 years, ASA 3.0, OR time 88 minutes, estimated blood loss 200 ml, and the length of stay 10 days. The overall complications were 8.8% (THR), and 9.1% (HA), respectively. The mortality rates for the patients were: at the 1-year (9.5% THR vs 16.3% HA), at the 3-year (15.3% THR vs 24.0% HA), and at the 5-year (19.7% THR vs 26.9% HA), respectively.

Our data demonstrated similar peri-operative data and short-term complications between the two groups. There was a difference in the mortality rates between the two groups at all 3-time intervals following the surgery. This could be a reflection of the patient selection bias for each of the operations.

We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN.

This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs.

We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types.

Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%).

Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94).

Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients.

Intertrochanteric fractures are common, accounting for nearly 30% of all fracture related admissions. Some have suggested that these fractures should be treated in community hospitals so as not to tax the resources of Level One trauma centers. Since many factors predictive of fixation failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation comparing trauma fellowship trained surgeons to non-fellowship trained community surgeons to see if these fractures can be treated successfully in either setting.

Using our hospital system's trauma database, we identified 100 consecutive patients treated with cephalomedullary nails by traumatologists, and 100 consecutive patients treated by community surgeons. Quality of reduction, neck shaft angle (NSA), tip-to apex distance (TAD) were compared.

The mean TAD for the trauma group was 10mm compared to 21mm for the community group (p<0.001). The mean postoperative NSA for the trauma group was 133 degrees compared to 127 degrees for the community group (p<0.001). The mean difference in the NSA of the fractured side compared to the normal hip was 2.5 degrees of valgus in the trauma group compared to 5 degrees of varus for the community group (p<0.001). There were 93 good reductions in the trauma group compared to 19 in the community group (p<0.001). There were no poor reductions in the trauma group and 49 poor reductions in the community group (p<0.001).

Fellowship trained traumatologists achieved significantly more accurate reductions and implant placement during cephalomedullary nailing of intertrochanteric hip fractures.

Industries such as agriculture, construction and military have stringent rules about hearing protection due to the risk of noise induced hearing loss (NIHL). Due to the use of power tools, orthopaedic staff may be at risk of the same condition. The UK Health and Safety Executive (HSE) have clear standards as to what is deemed acceptable occupational noise levels on an A-weighted and C weighted scale. This review is aimed to assess evidence on noise exposure testing within Orthopaedic theatres to see if it exceeds the HSE regulations.

A targeted search of online databases PUBMED and EMBASE was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) principles. This review was registered prospectively in PROSPERO. An eligibility criterion identifying clinical studies which assessed noise exposure for Orthopaedic staff in theatres were included. Noise exposure data was extracted from these studies and a comparison was made with A weighted and C weighted acceptable exposure levels as quoted in the HSE regulations.

Fourteen papers were deemed eligible, which reviewed 133 Orthopaedic operations and 64 Orthopaedic instruments. In total, 61% (81 of 132) of Orthopaedic operations and 70% (45 of 64) of instruments exceeded the noise regulations on an A weighted scale. 22% (10 of 46) of operations exceeded the maximum C weighted peak acceptable noise level.

Orthopaedic instruments and operations can exceed safe occupational noise levels. NHS Trusts have clear policies about noise exposure in the workplace but have yet to identify Orthopaedic theatres as a potential at risk area. Orthopaedic staff need education, monitoring and protection whereas Employers and Occupational Health should consider assessments to identify at risk staff in Orthopaedic theatres and offer preventative methods from NIHL.

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.

A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance.

13638 records were included (72% female). 9867 received a SHS (72%).

No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's.

There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations.

Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS.

Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

The last two decades have seen remarkable technological advances in total hip arthroplasty (THA) implant design. Porous ingrowth surfaces and highly crosslinked polyethylene (HXLPE) have been expected to dramatically improve implant survivorship. The purpose of the present study was to evaluate survival of contemporary cementless acetabular components following primary THA.

16,421 primary THAs performed for osteoarthritis between 2000 and 2019 were identified from our institutional total joint registry. Patients received one of 12 contemporary cementless acetabular designs with HXLPE liners. Components were grouped based on ingrowth surface into 4 categories: porous titanium (n=10,952, mean follow-up 5 years), porous tantalum (n=1223, mean follow-up 5 years), metal mesh (n=2680, mean follow-up 6.5 years), and hydroxyapatite (HA) coated (n=1566, mean follow-up 2.4 years). Kaplan-Meier analyses were performed to assess the survivorship free of acetabular revision. A historical series of 182 Harris-Galante-1 (HG-1) acetabular components was used as reference.

The 15-year survivorship free of acetabular revision was >97% for all 4 contemporary cohorts. Compared to historical control, porous titanium (HR 0.06, 95% CI 0.02–0.17, p<0.001), porous tantalum (HR 0.09, 95%CI 0.03–0.29, p<0.001), metal mesh (HR 0.11, 95%CI 0.04–0.31, p<0.001), and HA-coated (HR 0.14, 95%CI 0.04–0.48, p=0.002) ingrowth surfaces had significantly lower risk of any acetabular revision. There were 16 cases (0.1%) of acetabular aseptic loosening that occurred in 8 (0.07%) porous titanium, 5 (0.2%) metal mesh, and 3 (0.2%) HA-coated acetabular components. 7 of the 8 porous titanium aseptic loosening cases occurred in one known problematic design. There were no cases of aseptic loosening in the porous tantalum group.

Modern acetabular ingrowth surfaces and HXLPE liners have improved on historical results at the mid-term. Contemporary designs have extraordinarily high revision-free survivorship, and aseptic loosening is now a rare complication.

At mid-term follow-up, survivorship of contemporary uncemented acetabular components is excellent and aseptic loosening occurs in a very small minority of patients.

Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l (13ppb, 221nmol/l). Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Global longitudinal strain (GLS) is an echocardiography measurement known to be more sensitive than ejection fraction at diagnosing early cardiomyopathies. The extent of cardiovascular injury, as measured by GLS, in patients with elevated blood cobalt levels has not previously been examined.

Sixteen patients with documented blood cobalt ion levels above 13µg/l were identified from a regional arthroplasty database. They were matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. All patients underwent electrocardiogram and echocardiogram assessment for signs of cardiomyopathy including GLS.

Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l (495nmol/l) compared to 0.01µg/l (0.2nmol/l) in the control group. There was no difference or correlation in ejection fraction (EF), left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009).

For the first time, this study has demonstrated reduced cardiac function in the presence of normal EF as assessed by GLS in patients with elevated cobalt above 13µg/l. As GLS is a more sensitive measure of systolic function than EF, routine echocardiogram assessment including GLS should be performed in all patients with MoM hip arthroplasties and elevated blood cobalt above 13µg/l. Further work is recommended to assess if these cardiac changes are present in patients with elevated blood cobalt levels below 13µg/l.

In this RCT the primary aim was to assess whether a short (125mm) Exeter V40 stem offered an equivalent hip specific function compared to the standard (150mm) stem when used for cemented total hip arthroplasty (THA). Secondary aims were to evaluate health-related quality of life (HRQoL), patient satisfaction, stem height and alignment, radiographic loosening, and complications between the two stems.

A prospective multicentre double-blind randomised control trial was conducted. During a 15-month period, 220 patients undergoing THA were randomised to either a standard (n=110) or short (n=110) stem Exeter. There were no significant (p≥0.065) differences in preoperative variables between the groups. Functional outcomes and radiographic assessment were undertaken at 1- and 2-years.

There were no differences (p=0.428) in hip specific function according to the Oxford hip score at 1-year (primary endpoint) or at 2-years (p=0.767) between the groups. The short stem group had greater varus angulation (0.9 degrees, p=0.003) when compared to the standard group and were more likely (odds ratio 2.42, p=0.002) to have varus stem alignment beyond one standard deviation from the mean. There were no significant (p≥0.083) differences in the Forgotten joint scores, EuroQol-5-Dimension, EuroQol-VAS, Short form 12, patient satisfaction, complications, stem height or radiolucent zones at 1 or 2-years between the groups.

The Exeter short stem offers equivalent hip specific function, HRQoL, patient satisfaction, and limb length when compared to the standard stem at 2-years post-operation. However, the short stem was associated with a greater rate of varus malalignment which may influence future implant survival.

The variables involved in a robotic THA can exceed 52: many parameters as pelvic orientation with CT scan, templating, offset, and leg-length, acetabular reaming, femoral osteotomy, mapping the anatomy; predefining safe zones, robotic execution, femoral head size, thickness of PE etc. with several variables for each parameter, with a total number of variables exceeding 52. This familiar number is the number of cards in a standard deck. The number of possible combinations (factorial 52! = 10^67) to shuffle the cards (and may be to perform a THA) is greater than the number of atoms on earth! Thinking that artificial intelligence and robotics can solve these problems, some surgeons and implant manufacturers have turned to artificial intelligence and robotics.

We asked two questions:1) can robot with artificial intelligence really process 52 variables that represent 10^67 combinations? 2) the safety of the technology was ascertained by interrogating Food and Drug Administration (FDA) database about software-related recalls in computer-assisted and robotic arthroplasty [1], between 2017 and 2022.

1)

The best computers can only calculate around 100 thousand billion combinations (10^14), and with difficulty: it takes more than 100 days to arrive at this number of digits (10^14) after the decimal point for the number π (pi). We can, therefore, expect the robot to be imperfect.

Hip surgeon is as intelligent as a robot and almost twice as safe.

Isolated liner exchange with highly crosslinked polyethylene (HXLPE) is an option to address polyethylene wear and osteolysis after total hip arthroplasty (THA). The liner can be fixed with either the original locking mechanism or cemented into the acetabular cup. Whether the method used for fixation of HXLPE liner has any bearing on the outcomes 10 to 15 years after surgery is still unclear.

Data for all patients who had undergone isolated liner exchange surgery with HXLPE in our institution between August 2000 and January 2015 were retrieved. Patients were classified according to the locking mechanism used (original locking mechanism or cemented). Survivorship and revision rates were compared among different subgroups. A total of 86 isolated liner exchanges were performed and patients had a mean duration of follow-up of 13 years (range, 5 to 22). 50 patients had the new liner cemented and the other 36 patients used the original locking mechanism.

20 patients (23.3%) had complications, with dislocation being the most common (7). 10 of them (12.6%) required re-revision surgery. Overall estimated mean survivorship was 19.2 years. There was no significant difference in the re-revision rate between original locking mechanism (11.1%) and cementation (12.0%) for the fixation of HXLPE (p=0.899). Using the Kaplan-Meier survival analysis, the revision-free survival of HXLPE fixed with original locking mechanism and cementation were 94.1% and 93.2%, respectively, at 10 years, and were 84.7% and 81.3%, respectively, at 20 years (p=0.840).

The re-revision rate and the revision-free survival of liner exchange surgery using HXLPE liner were not affected by the fixation technique used. Both cementing a HXLPE liner or using the original locking mechanism were associated with good survivorship at 13 years follow up.

The best treatment method of large acetabular bone defects at revision THR remains controversial. Some of the factors that need consideration are the amount of residual pelvic bone removed during revision; the contact area between the residual pelvic bone and the new implant; and the influence of the new acetabular construct on the centre of rotation of the hip. The purpose of this study was to compare these variables in two of the most used surgical techniques used to reconstruct severe acetabular defects: the trabecular metal acetabular revision system (TMARS) and a custom triflanged acetabular component (CTAC).

Pre- and post-operative CT-scans were acquired from 11 patients who underwent revision THR with a TMARS construct for a Paprosky IIIB defect, 10 with pelvic discontinuity, at Royal Adelaide Hospital. The CT scans were used to generate computer models to virtually compare the TMARS and CTAC constructs using a semi-automated method. The TMARS construct model was calculated using postoperative CT scans while the CTAC constructs using the preoperative CT scans. The bone contact, centre of rotation, inclination, anteversion and reamed bone differences were calculated for both models.

There was a significant difference in the mean amount of bone reamed for the TMARS reconstructions (15,997 mm³) compared to the CTAC reconstructions (2292 mm³, p>0.01). There was no significant difference between overall implant bone contact (TMARS 5760mm² vs CTAC 5447mm², p=0.63). However, there was a significant difference for both cancellous (TMARS 4966mm² vs CTAC 2887mm², p=0.008) and cortical bone contact (TMARS 795mm² vs CTAC 2560mm², p=0.001). There was no difference in inclination and anteversion achieved. TMARS constructs resulted on average in a centre of rotations 7.4mm more lateral and 4.0mm more posterior.

Modelling of two different reconstructions of Paprosky IIIB defects demonstrated potential important differences between all variables investigated.

Severe heterotopic ossification (grade III and IV) after contemporary total hip arthroplasty (THA) requiring excision is very uncommon. We performed a systematic review of the literature, and report a new case series with operative treatment after primary uncemented THA.

A systematic review identified papers describing patients who had excision of heterotopic ossification (HO) after contemporary THA, defined as performed after 1988. Concepts of hip arthroplasty, heterotopic ossification, and surgical excision were searched in MEDLINE, Embase, and Scopus, from database inception to November 2022. Inclusion criteria were: articles that included specific patient data on grade of heterotopic ossification, operative procedure, and prophylaxis. Studies were screened for inclusion by two independent reviewers. Extracted data included demographic data, interval from index surgery to excision, clinical results, and complications. One surgeon performed reoperation for ankylosis of primary THA in three patients with severe pain and deformity.

Seven case series or case report studies were included. There were 41 patients, with grade III or IV HO, that had excision, and in five patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation, one gastrointestinal complication, and two recurrences. Treatment of the three patients, with wide excision of peri-articular bone, selective exchange of components, and peri-operative irradiation prophylaxis, was successful in improving motion and deformity.

There is insufficient data on the treatment of severe symptomatic HO after contemporary THA. Prophylaxis with low-dose irradiation was successful to prevent recurrence. Multicenter studies will be needed to determine the optimum timing and prognosis for treatment.

Uncemented femoral components have been used in total hip arthroplasties (THAs) for over three decades. Data on long-term performance of hydroxyapatite-coated femoral stems is however limited. This study reports the survivorship of a collarless, straight, hydroxyapatite-coated femoral stem (Omnifit HA, Osteonic) with a minimum of 20 years of follow-up.

We reviewed the results of 165 THAs using Omnifit HA in 138 patients performed between August 1993 and December 1999. The mean age at surgery was 46 years (range 20 – 77 years). Avascular necrosis was the most common cause of THA, followed by ankylosing spondylitis and primary osteoarthritis. The mean follow-up was 22 years (range 20–31 years). At 20 and 25 years, 113 arthroplasties (91 patients) and 63 arthroplasties (55 patients) were available for follow-up respectively, while others had deceased or were lost to follow-up.

Kaplan-Meier survivorship analysis was performed to evaluate the survival of the femoral component. Radiographs were reviewed at regular intervals, and implant stability was evaluated using Engh classification.

Seven out of 165 stems were revised upon the latest follow-up; that included one case of aseptic loosening with revision done at 15 years, three peri-prosthetic fractures, two infections, and one recurrent dislocation.

At 20 years, survivorship with revision of the femoral stem for any cause and aseptic loosening as the endpoint was 96.0% (95% CI, 92.6 – 99.5%) and 98.4% (95% CI, 96.2 – 100%) respectively. At 25 years, the corresponding survivorship rates were 94.5% (95% CI, 91.9 – 97.3%) and 98.1% (95% CI, 95.7 – 99.6%) respectively.

Radiographic findings of stable bony fixation were seen in 86 stems (76.1%) and those of loosening in 4 stems (3.5%) at 20 years. All patients with radiographic signs of loosening were asymptomatic and did not require revision.

The Omnifit HA femoral stem offered promising long-term survivorship into the third decade.

The Norwegian Arthroplasty Register (NAR) started collecting data on total hip arthroplasty (THA) in 1987. Very long-term results of implants for THA are scarce. We aimed to show long-term results for the three most used femoral stems, operated from 1987.

We included the uncemented Corail femoral stem (n=66,309) and the cemented Exeter stem (n=35,050) both of which are currently in frequent use. In addition, we included the Charnley stem (n=32,578, in use until 2014). To ensure comparable conditions, stems fixated with low viscosity cement and stems revised due to infections were excluded. Differences in risk of revision (all reasons and stem revisions) were assessed with Kaplan-Meier and Cox regression analyses with adjustment for possible confounding from age, sex and diagnosis (OA, other). Stem revision was defined as a revision caused by loosening of the stem, dislocation, osteolysis in the femur, or periprosthetic femur fracture, and in which the femoral component was removed or exchanged.

The median and max follow-up for Corail, Exeter and Charnley were 6.3 (33.1), 8.0 (34.2) and 13.1 (34.3) respectively. Thirty years survival estimates for Corail, Exeter and Charnley stems were 88.6% (CI:85.8–90.9%), 86.7% (83.7–89.2%) and 87.1% (85.4–88.5%) respectively with stem revision as endpoint, and 56.1% (CI:53.1–59.1%), 73.3% (70.5–76.1%) and 80.2% (78.4–82.0%) with all THA revisions as endpoint. Compared to the Corail, the Exeter (HRR=1.3, CI:1.2–1.4) and the Charnley (HRR=1.9, CI:1.7–2.1) had a significant higher risk of stem revision. Women 75 years and older had better results with the cemented stems. Analyses accounting for competing risk from other causes of revision did not alter the findings.

The uncemented Corail stem performed well in terms of stem revisions for stem-related revision causes compared to two frequently used cemented stems with very long follow-up. The differences between the three stems were small.

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively.

This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates.

A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012).

Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design.

Periacetabular osteotomy (PAO) is an established treatment for developmental hip dysplasia (DDH) in young adults and can also be utilised in the management of femoroacetabular impingement (FAI) with acetabular retroversion. This study used a national registry to assess the outcomes of PAO for DDH and FAI.

PAOs recorded in the UK Non-Arthroplasty Hip Registry between 2012 and November 2022 were identified along with recorded patient and surgical characteristics. Cases were grouped according to the primary pathology (DDH or FAI). Patient reported outcome measures (PROMs) captured included the International Hip Outcome Tool (iHOT)-12 (primary outcome) and the EuroQol-5 Dimensions (EQ-5D) index preoperatively and at 6 months, 1, 2, and 5 years post-operatively.

1,087 PAOs were identified; 995 for DDH (91%), 98 for FAI (9%). Most patients (91%) were female. The DDH group were significantly older (mean 31.7 years) than the FAI group (25.4 years) but had similar body mass index (mean 25.7kg/m2). Overall, significant (all p<0.0001) iHOT-12 and EQ-5D improvement (delta) vs baseline pre-operative scores were achieved at 6 months (mean iHOT-12 improvement +27.4 (95%CI 25.3 to 29.5); n=515) and maintained out to 5 years (+30.0 (21.4 to 38.6); n=44 [9.8% of those eligible for follow-up at 5 years]), at which point 71% and 55% of patients continued to demonstrate a score improvement greater than or equal to the minimum clinically important difference (≥13 points) and substantial clinical benefit (≥28 points) for iHOT-12 respectively.

This study demonstrates excellent functional outcomes following PAO undertaken for DDH and FAI in the short to medium term in a large national registry.

Ceramic bearing fractures are rare events, but mandate revision and implantation of new bearings. Revisions using metal heads have been reported to lead to gross volumetric head wear (due to abrasive retained ceramic micro-debris), cobalt toxicity, multi-organ failure and death. Such complications are widely published (50+ reports), yet we know that patients continue to be put at risk. Using data from the NJR and AOANJRR, this study seeks to compare the risk of re-revision and death by revision bearing combination following a ceramic bearing fracture.

Data were extracted from the NJR and AOANJRR, identifying revisions for ceramic bearing fracture. Subsequent outcomes of survival, re-revision and death were compared between revision bearing combinations (ceramic-on-ceramic, ceramic-on-polyethylene, and metal-on-polyethylene).

366 cases were available for analysis from the NJR dataset (MoP=34, CoP=112, CoC=221) and 174 from the AOANJRR dataset (MoP=17, CoP=44, CoC=113). The overall incidence rate of adverse outcome (revision or death) was 0.65 for metal heads and 0.23 for ceramic head articulations (p=0.0012) across the whole time period (NJR). Kaplan-Meir survival estimates demonstrate an increased risk of both re-revision and death where a metal head has been used vs a ceramic head following revision for ceramic fracture.

There are few decisions in arthroplasty surgery that can lead to serious harm or death for our patients, but revision using a metal head following ceramic bearing fracture is one of them. This study enhances the signal of what is already known but previously only reported as inherently low-level evidence (case reports and small series) due to event rarity. Use of a metal head in revision for ceramic fracture represents an avoidable patient safety issue, which revision guidelines should seek to address.

Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health.

An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons.

The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001).

Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons.

Contemporary acetabular reconstruction in major acetabular bone loss often involves the use of porous metal augments, a cup-cage construct or custom implant. The aims of this study were: To determine the reproducibility of a reconstruction algorithm in major acetabular bone loss. To determine the subsequent success of reconstruction performed in terms of re-operation, all-cause revision and Oxford Hip Score (OHS) and to further define the indications for custom implants in major acetabular bone loss.

Consecutive series of Paprosky Type III defects treated according to a reconstruction algorithm. IIIA defects were planned to use a superior augment and hemispherical cup.

IIIB defects were planned to receive either augment and cup, cup-cage or custom implant.

105 procedures in cohort 100 patients (5 bilateral) with mean age 73 years (42–94).

IIIA defects (50 cases) − 72.0% (95%CI 57.6–82.1) required a porous metal augment the remainder treated with a hemispherical cup alone. IIIB defects (55 cases) 71.7% (95%CI 57.6–82.1) required either augments or cup-cage. 20 patients required a hemispherical cup alone and 6 patients received a custom-made implant.

Mean follow up of 7.6 years. 6 re-revisions were required (4 PJI, 2 peri-prosthetic fractures & 1 recurrent instability) with overall survivorship of 94.3% (95% CI 97.4–88.1) for all cause revision. Single event dislocations occurred in 3 other patients so overall dislocation rate 3.8%. Mean pre-op OHS 13.8 and mean follow-up OHS 29.8.

Custom implants were used in: Mega-defects where AP diameter >80mm, complex discontinuity and massive bone loss in a small pelvis (i.e., unable to perform cup-cage)

A reconstruction algorithm can >70% successfully predict revision construct which thereafter is durable with a low risk of re-operation. Jumbo cup utilized <1/3 of cases when morphology allowed. The use of custom implants has been well defined in this series and accounts for <5% of cases.

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA.

Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints.

The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years.

Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors.

Partial thickness abductor tendon tears are a significant source of recalcitrant laterally based hip pain. For those that fail conservative treatment, the results of endoscopic repair are highly successful with minimal morbidity. The principal burden is the protracted rehabilitation that is necessary as part of the recovery process. There is a wide gap between failed conservative treatment and successful surgical repair. It is hypothesized that a non-repair surgical strategy, such as a bioinducitve patch, could significantly reduce the burden associated recovery from a formal repair. Thus, the purpose of this study is to report the preliminary results of this treatment strategy.

Symptomatic partial thickness abductor tendon tears are treated conservatively, including activity modification, supervised physical therapy and ultrasound guided corticosteroid injections. Beginning in January 2022, patients undergoing hip arthroscopy for intraarticular pathology who also had persistently symptomatic partial thickness abductor tendon tears, were treated with adjunct placement of a bioinducitve (Regeneten) patch over the tendon lesion from the peritrochanteric space. The postop rehab protocol is dictated by the intraarticular procedure performed. All patients are prospectively assessed with a modified Harris Hip Score (mHHS) and iHOT and the tendon healing response examined by ultrasound.

Early outcomes will be presented on nine consecutive cases.

Conclusions - Will be summarized based on the preliminary outcomes to be reported.

Current estimates of periprosthetic fracture risk associated with femoral implants is mostly limited to revision only estimates and does not accurately represent stem performance. The aim of this study was to estimate the risk of surgically treated post-operative periprosthetic femoral fracture (POPFF) more accurately associated with frequently used femoral implants used for total hip arthroplasty (THA).

A cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020. Periprosthetic fractures were identified from prospectively collected revision records and national procedure coding records. Survival modelling was used to estimate POPFF incidence rates, adjusting for potential confounders. Subgroup analyses were performed for patients over 70 years, with non-osteoarthritic indications, and neck of femur fracture.

POPFF occurred in 0.6% (5100/809,832) of cases during a median (IQR) follow up of 6.5 (3.9 to 9.6) years. The majority of POPFF were treated with fixation after implantation of a cemented stem. Adjusted patient time incidence rates (PTIR) for POPFF varied by stem design, regardless of cement fixation. Cemented composite beam stems (CB stems) demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF versus the current gold standard polished taper slip cemented stem.

POPFF account for a quarter of all revisions following primary THA. Cemented CB stems are associated with the lowest POPFF risk. Stem design is strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when recommending femoral implants in those most at risk of POPFF.

Given the prolonged waits for hip arthroplasty seen across the U.K. it is important that we optimise priority systems to account for potential disparities in patient circumstances and impact. We set out to achieve this through a two-stage approach. This included a Delphi-study of patient and surgeon preferences to determine what should be considered when determining patient priority, followed by a Discrete Choice Experiment (DCE) to decide relative weighting of included attributes.

The study was conducted according to the published protocol ([https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071](https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071)). The Delphi study was performed online over 3 rounds with anonymous ranking and feedback. Included factors were voted as either Consensus in, Consensus out, or No Consensus• following an established scoring criterion. A final consensus meeting determined the prioritisation factors (and their levels) to be included in the DCE. The DCE was then conducted using an online platform, with surgeons performing 18 choice sets regarding which merited greater priority between two hypothetical patients. Results were collated and analysed using multinomial logit regression analysis (MNL).

For the Delphi study there were 43 responses in the first round, with a subsequent 91% participation rate. Final consensus inclusion was achieved for Pain; Mobility/Function; Activities of Daily Living; Inability to Work/Care; Length of Time Waited; Radiological Severity and Mental Wellbeing. 70 individuals subsequently contributed to the DCE, with radiological severity being the most significant factor (Coefficient 2.27 \[SD 0.31\], p<0.001), followed by pain (Coefficient 1.08 \[SD 0.13\], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 \[SD 0.02\], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months.

These results present a new method of determining comparative priority for those on primary hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required.

Adult hip dysplasia AHD is a complex 3D pathology of lateral coverage, version and/or volume and is often associated with increased femoral anteversion. The Mckibbin index MI is the combination of acetabular version AV and femoral version FV and is used as a measure of anterior hip Stability/ Impingement(1). The Bernese Periacetabular osteotomy PAO is a powerful tool in treating AHD, but it does not address FV. De-rotational femoral osteotomies FO increases risk of complications, operative time and might condemn the patient to Secondary osteotomies to balance the gait. We aim to investigate the effect of MI and FV on PROMs in patients undergoing PAO only.

593 PAOs identified on the Local Hip preservation registry between 01/2013 and 7/2023. PAOs for retroversion, residual Perthes and those combined with FO were excluded. Patients with no available PROMS at 2 years were excluded. Independent variables were collected from E-notes and imaging including MI and FV. A multiple linear regression analysis was performed against preoperative iHot12, and iHot12 change at 2years.

The mean FV was 18.86± 12.4 SD. Mean MI was 36.07, SD 15.36. Mean preop iHot12 score was 29.83 ± 17.38 SD. Mean change in iHot12 at 2 years was+36.47 ± 28.44 SD. Females and a higher BMI were statistically correlated to a lower preoperative iHot12. A lower preop iHot12 score and a higher preop AI were correlated to a bigger change in iHot12 at 2years with statistical significance. MI and FV were not found to have a statistically significant correlation with Outcome measures,

An increased Mckibbin index and femoral anteversion were not correlated with worse outcomes at two years. PAO alone in the presence of increased femoral anteversion avoids risks associated with FO which can be performed later if required.

Total hip replacement (THR) is one of the most common and cost-effective elective surgical procedures. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of locally negotiated prices. This study aims to estimate the total burden of elective THR to the NHS, expenditure on implants, and different scenarios of cost changes if implant selection changed for different patient groups.

Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision THR in the 10-year period 2008–2017 and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants.

The NHS spent over £4.76 billion performing 702,381 THRs between 2008–2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low.

The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice. The HIPPY programme will be conducting practice surveys, discrete choice experiments and a large randomised controlled trial of cemented, uncemented and hybrid fixation in THR for patients under 70 to answer uncertainties.

Gluteal Tendinopathy is a poorly understood condition that predominantly affects post-menopausal women. It causes lateral hip pain, worse when lying on the affected side or when walking up a hill or stairs. It has been labelled ˜Greater Trochanteric Pain Syndrome” a name that recognises the lack of understanding of the condition.

Surgical reconstruction of the gluteal cuff is well established and has been undertaken numerous times over the last 16 years by the senior author (AJL). However, the quality of collagen in the tendons can be very poor and this leads to compromised results. We present the results of gluteal cuff reconstruction combined with augmentation using a bioinductive implant.

14 patients (11 female, 3 male; mean age 74.2 ± 6.3 years) with significant symptoms secondary to gluteal tendinopathy that had failed conservative treatment (ultrasound guided injection and structured physiotherapy) underwent surgical reconstruction by the senior author using an open approach. In all cases the iliotibial band was lengthened and the trochanteric bursa excised. The gluteal cuff was reattached using Healicoil anchors (3–5×4.75mm anchors; single anchors but double row repair) and then augmented using a Regeneten patch. Patients were mobilised fully weight bearing post-operatively but were asked to use crutches until they were no longer limping. All had structured post-surgery rehabilitation courtesy of trained physiotherapists.

There were no post-operative complications and all patients reported an improvement in pain levels (Visual Analogue Scale 7.8 pre-op; 2.6 post-op) and functional levels (UCLA Activity Score 3.5 pre-op; 7.1 post-op) at 6 months post surgery.

Surgery for gluteal tendinopathy produces good outcomes and the use of Regeneten as an augment for poor quality collagen is seemingly a safe, helpful addition. Further comparative studies would help clarify this.

The significance of periprosthetic fractures about a total hip arthroplasty (THA) is becoming increasingly important. Recent studies have demonstrated post-operative periprosthetic fracture rates are higher amongst cemented polished taper slip (PTS) stem designs compared to collared cementless (CC) designs.

However, in the National Joint Registry, the rate of intra-operative periprosthetic femoral fractures (IOPFF) with cementless implant systems remains higher (0.87% vs 0.42%. p <0.001) potentially leading to more post-operative complications.

This study identifies the incidence of IOPFF, the fracture subtype and compares functional outcomes and revision rates of CC femoral implants with an IOPFF to CC stems and PTS stems without a fracture.

5376 consecutive CC stem THA, carried out through a posterior approach were reviewed for IOPFF. Each fracture was subdivided into calcar fracture, greater trochanter (GT) fracture or shaft fracture.

1:1:1 matched analysis was carried out to compare Oxford scores at one year. Matching criteria included; sex (exact), age (± 1 year), American Society of Anaesthesiologists (ASA) grade (exact), and date of surgery (± 6 months).

Electronic records were used to review revision rates.

Following review of the CC stems, 44 (0.8%) were identified as having an IOPFF. Of these 30 (0.6%) were calcar fractures, 11 (0.2%) GT fractures and 3 (0.06%) were shaft fractures. There were no shaft penetrations.

Overall, no significant difference in Oxford scores at one year were observed when comparing the CC IOPFF, CC non-IOPFF and PTS groups.

There were no CC stems revised for any reason with either a calcar fracture or trochanteric fracture within the period of 8 years follow-up.

IOPFF do occur more frequently in cementless systems than cemented. The majority are calcar and GT fractures. These fractures, when identified and managed intra-operatively, do not have worse functional outcomes or revision rates compared to matched non-IOPFF cases.

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning.

The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty.

All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation.

A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%)

Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.

Proximal hamstring tendon avulsion from the ischial tuberosity is a significant injury, with surgical repair shown to have superior functional outcomes compared to non-surgical treatment. However, limited data exists regarding the optimal rehabilitation regime following surgical repair. The aim of this study was to investigate patient outcomes following repair of proximal hamstring tendon avulsions between a conservative (CR) versus an accelerated rehabilitation (AR) regimen.

This prospective randomized controlled trial (RCT) randomised 50 patients undergoing proximal hamstring tendon repair to either a braced, partial weight-bearing rehabilitation regime (CR=25) or an accelerated, unbraced regime, that permitted full weight-bearing as tolerated (AR=25).

Patients were evaluated pre-operatively and at 3 and 6 months post-surgery, via patient-reported outcome measures (PROMs) including the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT) and 12-item Short Form Health Survey (SF-12). Primary analysis was per protocol and based on linear mixed models.

Both groups were matched at baseline with respect to patient characteristics. All PROMs improved (p>0.05) and, while the AR group reported a significantly better Physical Component Score for the SF-12 at 3 months (p=0.022), there were no other group differences. Peak isometric hamstrings strength and peak isokinetic quadriceps and hamstrings torque symmetry were all comparable between groups (p>0.05). Three re-injuries have been observed (CR=2, AR=1).

After proximal hamstring repair surgery, post-operative outcomes following an accelerated rehabilitation regimen demonstrate comparable outcomes to a traditionally conservative rehabilitation pathway, albeit demonstrating better early physical health-related quality of life scores, without an increased incidence of early re-injury.

The aims were to assess whether vitamin D deficiency influenced mortality risk for patients presenting with a hip fracture.

A retrospective study was undertaken including all patients aged over 50 years that were admitted with a hip fracture to a single centre during a 24-month period. Serum vitamin D levels were assessed. Patient demographics and perioperative variables and mortality were collected. Cox regression analysis (adjusting for confounding) was utilised to determine the independent association between serum vitamin D level and patient mortality.

The cohort consisted of 2075 patients with a mean age of 80.7 years and 1471 (70.9%) were female. 1510 (72.8%) patients had a serum vitamin D level taken, of which 876 (58.0%) were deficient (50nmol/l). The median follow up was 417 (IQR 242 to 651) days. During follow up there were 464 (30.7%) deaths. Survival at 1 year was significantly (p=0.003) lower for patients who were vitamin D deficient (71.7%, 95% confidence intervals (CI) 68.6 to 74.9) compared to those who were not (79.0%, 95% CI 75.9 to 82.3). Vitamin D deficiency was also independently associated with an increased mortality risk at 2-years (HR 1.25, 95% CI 1.03 to 1.53, p=0.025), but not at 1-year (p=0.057).

Hip fracture patients with vitamin D deficiency had an increased mortality risk. This risk was independent of confounders at 2 years. The role of measuring vitamin D levels in these patients is unclear. Improved public health policy about vitamin D may be required to reduce deficiency in this patient population.

MCID and PASS are thresholds driven from PROMS to reflect clinical effectiveness. Statistical significance can be derived from a change in PROMS, whereas MCID and PASS reflect clinical significance. Its role has been increasingly used in the world of young adult hip surgery with several publications determining the thresholds for Femoro-acetabular impingement FAI. To our knowledge MCID and PASS for patient undergoing PAO for dysplasia has not been reported.

593 PAOs between 1/2013 and 7/2023 were extracted from the Northumbria Hip Preservation Registry. Patients with available PROMS at 1year and/or 2years were included. PAOs for retroversion, residual Perthes and those combined with FO were excluded. MCID was calculated using the distribution method 0.5SD of baseline score(1). PASS was calculated using anchor method, ROC analysis performed, and value picked maximizing Youden index. A Logistic Regression analysis was performed to determine which independent variables correlated with achieving MCID and PASS.

The MCID threshold for iHOt12 was 8.6 with 83.4 and 86.3 % of patients achieved it at 1 and 2 years respectively. The PASS score at 1 and 2 year follow up was 43 and 44 respectively, with 72.6 and 75.2% achieving it at 1 and 2 year postop. At 2 years a Higher preop iHOT 12 was associated with not achieving MCID and PASS (p<0.05). Preop acetabular version was negatively correlated with achieving MCID and previous hip arthroscopy was negatively correlated with PASS.

The % of patients achieving MCID and PASS mimics that of FAI surgery (2). The negative correlation with preop iHOT12 reaffirms the importance of patient selection. The negative correlation of hip arthroscopy highlights the importance of having a high index of suspicion for dysplasia prior to hip arthroscopy and poorer outcomes of patients with mixed CAM and dysplasia pathology.

Implants in total hip replacement (THR) are associated with different clinical and cost-effectiveness profiles,. We estimate the costs and outcomes for NHS patients in the year after THR associated with implant bearing materials using linked routinely collected data.

We linked NJR primary elective THR patients for osteoarthritis to HES and National PROMs. We estimated health care costs, health-related quality of life indices, and revision risks, in the year after primary and revision THRs overall. We used generalised linear models adjusting for patient and hospital characteristics and estimated 10-year cumulative probability of revision. We imputed utilities using chained equations for half the sample with missing PROMS.

We linked 577,973 elective primary THRs and 11,812 subsequent revisions. One year after primary THR, patients with the cemented THRs using cobalt chrome or stainless steel head with HCLPE liner/cup cost the NHS, on average, £13,101 (95%CI £13,080,£13,122), had an average quality-of-life score of 0.788 (95%CI 0.787,0.788), and a 10-year revision probability of 1.9% (95%CI 1.6,2.3). Compared to the reference, patients receiving a cemented THR with delta ceramic head and HCLPE liner/cup, hybrid THR with delta ceramic head and HCLPE liner/cup, and hybrid THR with alumina head and HCLPE liner/cup had lower 1-year costs (-£572 \[95% CI -£775,-£385\], -£346 \[-£501,-£192\], -£371 \[-£574,-£168\] respectively), better quality of life (0.007 \[95% CI 0.003,0.011\], 0.013 \[0.010,0.016\], 0.009 \[0.005,0.013\] respectively), and lower 10-year revision probabilities (1.4% \[1.03,2.0\], 1.5 \[1.3,1.7\], 1.6%\[1.2,2.1\] respectively).

Implant bearing materials are associated with varying mean costs and health outcomes after primary THR. Ours is the first study to derive costs and health outcomes from large, linked databases using multiple imputation methods to deal with bias. Our findings are useful for commissioning and procurement decisions and to inform a subsequent cost-effectiveness model with more granular detail on THR implant types.

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic.

These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines.

We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre.

We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated.

331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years).

Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted.

Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries.

A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head.

Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value < 0.001.

The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures.

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

Aims

The aim of this study was to examine the implant accuracy of custom-made partial pelvis replacements (PPRs) in revision total hip arthroplasty (rTHA). Custom-made implants offer an option to achieve a reconstruction in cases with severe acetabular bone loss. By analyzing implant deviation in CT and radiograph imaging and correlating early clinical complications, we aimed to optimize the usage of custom-made implants.

Aims

Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions.

Aims

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

Aims

Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

Aims

Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty.

Aims

It has been well documented in the arthroplasty literature that lumbar degenerative disc disease (DDD) contributes to abnormal spinopelvic motion. However, the relationship between the severity or pattern of hip osteoarthritis (OA) as measured on an anteroposterior (AP) pelvic view and spinopelvic biomechanics has not been well investigated. Therefore, the aim of the study is to examine the association between the severity and pattern of hip OA and spinopelvic motion.

Aims

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component.

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

Aims

Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures.

Aims

To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Aims

Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI.