The benefits of cell salvage autotransfusion are well reported. There is a common non-evidenced belief amongst revision arthroplasty surgeons that auto-transfusion is potentially contraindicated in infected revisions.

The aim is to study the immediate and delayed outcomes of using cell saver on patients undergoing PJI surgery.

Prospective cohort service evaluation registered with the local audit department. 20 PJI cases in 18 patients where cell saver was used over a period of 4 years. Intraoperative fluid and tissue samples were taken for culture. Blood culture from salvaged blood pre and post leucodepletion filter were sent for microbiological analysis. Data on type of surgery, blood loss, further allogenic transfusion and SIRS response was collected. Success of infection clearance was assessed using 2019 MSIS ORT. Five patients receiving autologous blood in non-infection cases were used as controls.

Mean age for the PJI group was 67.7 years, 67% female. 11 patients (67%) had 1st stage surgery and 5 (25%) underwent 2nd stage whereas 4 patients had single stage surgery. The mean calculated blood loss was 1398 mls (range 400–3000mls). 6 Patients required further allogenic transfusion. 16 patients received blood via a leuco-depletion filter. The same organism grown from tissues was identified in post-filter blood in 8/17 patients (47%).

2/20 have grown a different organism in post-filtered blood, _P.Acne._

2 patients developed SIRS upon auto-transfusion, however one was thought to be secondary to cementing. The control group had 443 mls mean amount of blood loss and 1 patient developed a SIRS response.

14/20 (70%) patients had successful clearance of infection (tier 1) 2 patients died prior to undergoing 2nd stage.

Using cell saver did not impact main outcome of infection clearance in PJI surgery. We would advocate its routine usage whilst avoiding direct collection of heavily contaminated blood.

Following the establishment of regional Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may have a detrimental impact on the care of patients with hip fractures in these hospitals. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs).

National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, consultant supervision in theatre, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs).

A total of 487,089 patients with hip fractures were included from 167 hospitals (23 MTCs and 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p<0.001) and mobilisation out of bed by first postoperative day (81.9% vs 79.7%, p<0.001). A lower proportion of patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p<0.001). However, there was significantly higher consultant surgeon and anaesthetist supervision rates during surgery in MTCs (71.8% vs 61.6%, p<0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p<0.001), and proportionately fewer MTC patients were discharged to their original residence (63.5% vs 60.4%, p<0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825).

This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, as their mortality rates are similar to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients.

The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach.

The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus.

In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection).

Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA.

Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates.

A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed.

Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria.

Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction.

These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%.

The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent.

The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC.

Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result.

All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process.

Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%.

Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441.

Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773).

Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement.

This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases.

Hip arthroscopy (HA) and pelvic osteotomy (PO) are surgical procedures used to treat a variety of hip pathology affecting young adults, including femoroacetabular impingement and hip dysplasia respectively. This study aimed to investigate the trends and regional variation in the provision of HA and PO across England from 2010 to 2023 to inform healthcare resource allocation.

We analysed the National Hospital Episode Statistics database for all HA and PO procedures in NHS England using specific OPCS-4 codes: HA: ‘W83+Z843’ or ‘W84+Z843’; PO: ‘X222+Z75’. We collected patient demographics, age, sex, and region of treatment. We performed descriptive and regression analyses to evaluate temporal trends in PO volume, age, sex and regional variation.

22,401 HAs and 1,348 POs were recorded between 2010 and 2023. The annual number of HAs declined by 28.4%, whilst the number of POs increased by 64% (p<0.001). Significantly more females underwent PO vs HA (90% vs 61.3%) and were older than males undergoing the same procedure (PO: 29.0±8.7 vs 25.8±9.2 years; HA: 36.8±12.0 years vs 35.8±11.2 years, p<0.001). For HA, the mean age of both sexes decreased by 3.3 and 2.9 years respectively (p<0.001), whereas the age of PO patients did not change significantly over the study period. There were significant regional variations with a mean incidence of 1.60/100,00 for HA (ranging from 0.70–2.66 per 100,000) and 0.43/100,000 for PO (ranging from 0.08–2.07 per 100,000).

We have observed a decline in HA volume in England, likely due to improved patient selection and the impact of COVID-19, whilst PO volume has significantly increased, with regional variation persisting for both procedures. These trends highlight the need for equitable HA and PO access to improve patient outcomes and call for strategic healthcare planning and resource allocation to reduce disparities and improve training opportunities.

Subtrochanteric femoral fractures are a subset of hip fractures generally treated with cephalomedullary nail fixation\[1\]. Single lag screw devices are most commonly-used, but integrated dual screw constructs have become increasingly popular\[2,3\]. The aim of this study was to compare outcomes of fixation of subtrochanteric femoral fractures using a single lag screw (Gamma3 nail, GN) with a dual screw device (InterTAN nail, IN). The primary outcome was mechanical failure, defined as lag screw cut-out, back-out, nail breakage or peri-implant fracture.

Consecutive adult patients (18yrs) with subtrochanteric femoral fracture treated in a single centre were retrospectively identified using electronic records. Patients that underwent surgical fixation using either a long GN (2010–2017) or IN (2017–2022) were included. Medical records and radiographs were reviewed to identify complications of fixation. Cox regression analysis was used to determine the risk of mechanical failure and secondary outcomes by implant design. Multivariable regression models were used to identify predictors of mechanical failure.

The study included 622 patients, 354 in the GN group (median age 82yrs, 72% female) and 268 in the IN group (median age 82yrs, 69% female). The risk of any mechanical failure was increased two-fold in the GN group (HR 2.44 \[95%CI 1.13 to 5.26\]; _p=0.024_). Mechanical failure comprising screw cut-out (_p=0.032_), back-out (_p=0.032_) and nail breakage (_p=0.26_) was only observed in the GN group. Technical predictors of failure included varus >5° for cut-out (OR 19.98 \[2.06 to 193.88\]; _p=0.01_), TAD;25mm for back-out (8.96 \[1.36 to 58.86\]; p=0.022) and shortening 1cm for peri-implant fracture (7.81 \[2.92 to 20.91\]; _p=<0.001_).

Our results demonstrate that an intercalated screw construct is associated with a lower risk of mechanical failure compared with the a single lag screw device. Intercalated screw designs may reduce the risk of mechanical complications for patients with subtrochanteric femoral fractures.

Arthroplasties are widely performed to improve mobility and quality of life for symptomatic knee/hip osteoarthritis patients. With increasing rates of Total Joint Replacements in the United Kingdom, predicting length of stay is vital for hospitals to control costs, manage resources, and prevent postoperative complications. A longer Length of stay has been shown to negatively affect the quality of care, outcomes and patient satisfaction. Thus, predicting LOS enables us to make full use of medical resources.

Clinical characteristics were retrospectively collected from 1,303 patients who received TKA and THR. A total of 21 variables were included, to develop predictive models for LOS by multiple machine learning (ML) algorithms, including Random Forest Classifier (RFC), K-Nearest Neighbour (KNN), Extreme Gradient Boost (XgBoost), and Na¯ve Bayes (NB). These models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance. A feature selection approach was used to identify optimal predictive factors. Based on the ROC of Training result, XgBoost algorithm was selected to be applied to the Test set.

The areas under the ROC curve (AUCs) of the 4 models ranged from 0.730 to 0.966, where higher AUC values generally indicate better predictive performance. All the ML-based models performed better than conventional statistical methods in ROC curves. The XgBoost algorithm with 21 variables was identified as the best predictive model. The feature selection indicated the top six predictors: Age, Operation Duration, Primary Procedure, BMI, creatinine and Month of Surgery.

By analysing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA and THR, and the XgBoost algorithm performed the best, in terms of accuracy of predictive performance. As this model was originally crafted at Ashford and St. Peters Hospital, we have naturally named it as THE ASHFORD OUTCOME.

Hip dysplasia is a common cause of hip pain in young adults. Pelvic osteotomy (PO) techniques are the gold standard for treating symptomatic patients, albeit technically demanding. This study aimed to (1) evaluate the 90-day complication rate, and (2) investigate the reasons, frequency and timing of reoperations following primary PO procedures.

We retrospectively analysed the National Hospital Episode Statistics database, examining all patients aged over 14 who underwent PO in NHS England hospitals from 2010 to 2023. We identified index procedures and reoperations using relevant OPCS-4 codes. We analysed patient demographics, 90-day complications, and readmission rates for ipsilateral metalwork removal, revision PO, hip arthroscopy (HA), and THR conversion, and calculated the mean time to reoperations.

This study included 1,348 PO cases (mean age: 28.7±9.1 years, 89.5% female). The mean hospital stay was 5.4±3.9 days, with a 90-day readmission rate of 0.52% at a mean of 51.0±17.2 days. The most common causes were infection (0.22%) and reoperation (0.15%). The 90-day rate of pulmonary embolism and deep vein thrombosis was 0.074%. One patient died within 90 days.

Overall, 810 patients (60.1%) were readmitted for a subsequent hip procedure at a mean of 2.12±1.90 years following their primary PO. Metalwork removal was required in 616 patients (45.7%) at a mean of 1.70±1.19 years. Readmission rates for revision PO, HA, and THR, were 4.23% (mean time: 2.89±0.82 years), 4.15% (mean time: 2.91±2.28 years) and 6.01% (mean time: 5.24±3.08 years) respectively.

This study highlights a low 90-day complication rate following primary PO, but a high reoperation rate, mainly for metalwork removal. We provide the most up-to-date report of revision PO, HA and THR conversion rates in England. These findings provide valuable insight that can facilitate informed decision-making, expectation-setting, and post-operative planning, also establishing a benchmark for future quality improvement.

This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions.

132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05.

There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication.

Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.

Current advice regarding implant choice is based on estimates of cost-benefit derived from implant survival to an endpoint of revision. Current estimates do not account for many implant failures which are treated with non-revision surgery and may not be accurate. The aim of this study was to estimate survival of major stem implant design groups to an endpoint of reoperation.

Primary total hip replacement and linked revision form the National Joint Registry (NJR) and Hospital Episode Statistics (HES) data linked by unique identifier were used. Survival of femoral implant groups (cemented stainless steel polished taper [PTSS], cemented cobalt chrome polished taper [PTCC], cemented composite beam [CB], collarless cementless [NCOL] and collared cementless [COL]) was estimated using Kaplan-Meier method.

809,832 patients with valid NJR and HES data from England, were included. Cumulative failure at ten years for PTSS increased overall from 2.9% (95%CI 2.8–2.9) to 3.6% (95%CI 3.6–3.7) after inclusion of reoperations. Cumulative failure at ten years for PTSS increased from 2.5% (95%CI 2.5–2.6) to 3.3% (95%CI 3.2–3.4), for PTCC increased from 3.8% (95%CI 3.5–4.0) to 5.4% (95%CI 5.1–5.6), for CB increased from 3.1% (95%CI 2.9–3.3) to 4.1% (95%CI 3.8–4.3), for NCOL increased from 3.4% (95%CI 3.3–3.5) to 3.9% (95%CI 3.8–4.0), and for COL increased from 2.5% (95%CI 2.4–2.6) to 3.1% (95%CI 2.9–3.2), after inclusion of reoperations.

Re-operation for internal fixation is as significant life event for the patient as revision. When a more inclusive metric is used, the patient and clinician's perspective on what constitutes a GIRFT implant may not be the same. Further work is required to update implant selection guidance in view of the change in implant performance.

As patient data continues to grow, the importance of efficient and precise analysis cannot be overstated. The employment of Generative Artificial Intelligence (AI), specifically Chat GPT-4, in the realm of medical data interpretation has been on the rise. However, its effectiveness in comparison to manual data analysis has been insufficiently investigated.

This quality improvement project aimed to evaluate the accuracy and time-efficiency of Generative AI (GPT-4) against manual data interpretation within extensive datasets pertaining to patients with orthopaedic injuries.

A dataset, containing details of 6,562 orthopaedic trauma patients admitted to a district general hospital over a span of two years, was reviewed. Two researchers operated independently: one utilised GPT-4 for insights via prompts, while the other manually examined the identical dataset employing Microsoft Excel and IBM® SPSS® software. Both were blinded on each other's procedures and outcomes. Each researcher answered 20 questions based on the dataset including injury details, age groups, injury specifics, activity trends and the duration taken to assess the data.

Upon comparison, both GPT-4 and the manual researcher achieved consistent results for 19 out of the 20 questions (95% accuracy). After a subsequent review and refined prompts (prompt engineering) to GPT-4, the answer to the final question aligned with the manual researcher's findings. GPT-4 required just 30 minutes, a stark contrast to the manual researcher's 9-hour analytical duration.

This quality improvement project emphasises the transformative potential of Generative AI in the domain of medical data analysis. GPT-4 not only paralleled the accuracy of manual analysis but also achieved this in significantly less time. For optimal accurate results, data analysis by AI can be enhanced through human oversight. Adopting AI-driven approaches, particularly in orthopaedic data interpretation, can enhance efficiency and ultimately improve patient care. We recommend future investigations on large and more varied datasets to reaffirm these outcomes.

The reliable production of _in vitro_ chondrocytes that faithfully recapitulate _in vivo_ development would be of great benefit for orthopaedic disease modelling and regenerative therapy(1,2). Current efforts are limited by off-target differentiation, resulting in a heterogeneous product, and by the lack of comparison to human tissue, which precludes detailed evaluation of _in vitro_ cells(3,4).

We performed single-cell RNA-sequencing of long bones dissected from first-trimester fetal limbs to form a detailed ‘atlas’ of endochondral ossification. Through 100-gene in-situ sequencing, we placed each sequenced cell type into its anatomical context to spatially resolve the process of endochondral ossification. We then used this atlas to perform deconvolution on a series of previously published bulk transcriptomes generated from _in vitro_ chondrogenesis protocols to evaluate their ability to accurately produce chondrocytes.

We then applied single-nuclear RNA-sequencing to cells from the best performing protocol collected at multiple time points to allow direct comparison between the differentiation of _in vitro_ and _in vivo_ cells.

We captured 275,000 single fetal cells, profiling the development of chondrocytes from multipotent mesenchymal progenitors to hypertrophic cells at full transcriptomic breadth. Using this atlas as the ground truth for evaluating _in vitro_ cells, we found substantial variability in cell states produced by each protocol, with many showing little similarity to _in vivo_ cells, and all exhibiting off-target differentiation.

Trajectory alignment between _in vivo_ and _in vitro_ single-cell data revealed key differences in gene expression dynamics between _in vitro_ and _in vivo cells,_ with several osteoblastic transcription factors erroneously unregulated _in vitro,_ including _FOXO1._

Using this information, we inhibited _FOXO1_ in culture to successfully increase chondrocyte yield _in vitro._

This study presents a new framework for evaluating tissue engineering protocols, using single-cell data to drive improvement and bring the prospect of true engineered cartilage closer to reality.

Different techniques have been described to address massive bone loss of the acetabulum in revision hip surgery. aMace has gained popularity as it provides customization aiming to restore hip centre and provide good initial stability in cases of large non-contained defects. It takes into account quality of host bone. Its porous defect filling scaffold provides an excellent surface for osteointegration.

Our aim was to assess the short and mid-term outcomes of patients who underwent revision surgery using aMace system.

Ethical approval was obtained. A retrospective study included all patients who had aMace between June 2013 and October 2022 allowing for a minimum of 12-months follow-up. Patients’ demographics, indication, bone-loss severity, reconstruction details, re-operation, complications, mortality, pain and function were assessed.

52 cases were performed by 13 surgeons with median 51 months follow-up. Median age was 72.7 years. 86.5% were female. Average BMI was 25.3. Average ASA grade was 3.

65% were classified as Paprosky IIIB and 32% were IIIA.

73% were found to have poor bone quality on CT. Main indication for aMace was massive bone loss/discontinuity secondary to aseptic loosening in 88.5%.

77% underwent single-stage revision. 53.8% had 2 or more previous revisions. 71% underwent stem revision in the same setting. 77% received a dual mobility bearing.

Re-operation rate was 5.7% for instability and femoral PPF. LLD was reported in 9.6%.

Permanent Sciatic nerve palsy occurred in 3.8% of the cases.

30-days mortality was 1.9%.

Statistically significant post-op improvements in pain and mobility were reported (p<0.001). None of the acetabular components have been revised.

Our study shows satisfactory surgical outcomes with a relatively low complication rate and significant pain and mobility improvements in the early to mid-term stages.

We recommend these costly cases to be done in highly specialist centres adopting MDT approach.

The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome.

Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score.

Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001).

Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.

Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications.

Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled.

We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters.

Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices.

Aims

Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

Aims

Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition.

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Aims

It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively.

Aims

To investigate the extent of bone development around the scaffold of custom triflange acetabular components (CTACs) over time.

Aims

The frequency of severe femoral retroversion is unclear in patients with femoroacetabular impingement (FAI). This study aimed to investigate mean femoral version (FV), the frequency of absolute femoral retroversion, and the combination of decreased FV and acetabular retroversion (AR) in symptomatic patients with FAI subtypes.

Aims

The aim of this study is to evaluate whether acetabular retroversion (AR) represents a structural anatomical abnormality of the pelvis or is a functional phenomenon of pelvic positioning in the sagittal plane, and to what extent the changes that result from patient-specific functional position affect the extent of AR.

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Aims

Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure.

Aims

The primary outcome was investigating differences in wear, as measured by femoral head penetration, between cross-linked vitamin E-diffused polyethylene (vE-PE) and cross-linked polyethylene (XLPE) acetabular component liners and between 32 and 36 mm head sizes at the ten-year follow-up. Secondary outcomes included acetabular component migration and patient-reported outcome measures (PROMs) such as the EuroQol five-dimension questionnaire, 36-Item Short-Form Health Survey, Harris Hip Score, and University of California, Los Angeles Activity Scale (UCLA).

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Aims

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality.

Aims

The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs.

Aims

This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Aims

Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients.

Aims

Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects.

Aims

The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS).

Aims

Hip dysplasia (HD) leads to premature osteoarthritis. Timely detection and correction of HD has been shown to improve pain, functional status, and hip longevity. Several time-consuming radiological measurements are currently used to confirm HD. An artificial intelligence (AI) software named HIPPO automatically locates anatomical landmarks on anteroposterior pelvis radiographs and performs the needed measurements. The primary aim of this study was to assess the reliability of this tool as compared to multi-reader evaluation in clinically proven cases of adult HD. The secondary aims were to assess the time savings achieved and evaluate inter-reader assessment.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

It is anecdotally thought that a good outcome from the first of staged total hip arthroplasties (THAs) is predictive of benefit on the contralateral side. The objective was to determine whether outcome from the first THA could be used to predict outcome from the second, contralateral THA.

A retrospective cohort study of consecutive patients undergoing staged THAs at a UK arthroplasty centre over 25-years (1995–2020). A control THA group was identified and matched for age, gender, BMI, implant and diagnosis. One-year patient-reported outcome data was available for 91% 1543/1700.

1700 patients who underwent staged THA were compared to 1700 matched controls. Preoperative status was comparable for pain, function, and modified Harris hip score (mHHS, mean 41 SD 13 for both groups).

At one year, there was a 2% dissatisfaction rate in all groups (first of staged THAs, second of staged THAs and controls). Groups were similar in terms of pain, function and mHHS (mean 88 SD 11 for all groups). For every 100 patients undergoing staged THAs, 87 had a bilateral good outcome (mHHS >70 both), 11 had unilateral poor outcome (mHHS >70 one, <70 other) and 2 had bilateral poor outcome (mHHS <70 both).

If the first THA had a good outcome, the relative risk of a bad outcome was 20% less than for controls (RR 0.8 95% CI 0.6–1.1). If the first THA had a poor outcome, the risk of a second poor outcome was 4.5 times higher (RR 4.5 95% CI 3.2–6.4), increasing from 6% to 29% (absolute risk).

Patients undergoing staged THAs with a good outcome from the first THA were less likely to have a bad outcome with the second. Risk of a poor outcome after a previous successful THA was 6% but rose to almost 30% with a previous poor outcome. This remained after correcting for patient variables including gender, age, BMI and diagnosis, indicating a potentially novel independent risk factor for poor outcome from staged THA.

Pelvic discontinuity is a separation through the acetabulum with the ilium displacing superiorly and the ischium/pubis displacing inferiorly. This is a biomechanically challenging environment with a high rate of failure for standard acetabular components. The cup-cage reconstruction involves the use of a highly porous metal cup to achieve biological bone ingrowth on both sides of the pelvic discontinuity and an ilioischial cage to provide secure fixation across the discontinuity and bring the articulating hip center to the correct level. The purpose of this study was to report long term follow up of the use of the cup-cage to treat pelvic discontinuity.

All hip revision procedures between January 2003 and January 2022 where a cup-cage was used for a hip with a pelvic discontinuity were included in this retrospective review. All patients received a Trabecular Metal Revision Shell with either a ZCA cage or TMARS cage (Zimmer-Biomet Inc.). Pelvic discontinuity was diagnosed on pre-operative radiographs and/or intraoperatively. Kaplan-Meier survival analysis was performed with failure defined as revision of the cup-cage reconstruction.

Fifty-seven cup-cages in 56 patients were included with an average follow-up of 6.25 years (0.10 to 19.98 years). The average age of patients was 72.09 years (43 to 92 years) and 70.2% of patients were female. The five year Kaplan-Meier survival was 92.0% (95% CI 84.55 to 99.45) and the ten year survival was 80.5% (95% CI 58.35 to 102.65). There were 5 major complications that required revision of the cup-cage reconstruction (3 infections and 2 mechanical failures). There were 9 complications that required re-operation without revision of the cup-cage reconstruction (5 dislocations, 3 washouts for infection and one femoral revision for aseptic loosening).

In our hands the cup-cage reconstruction has provided a reliable tool to address pelvic discontinuity with an acceptable complication rate.

Osteolysis, fractures, and bone destruction caused by osteomyelitis or metastasis can cause large bone defects and present major challenges during acetabular reconstruction in total hip arthroplasty. We sought to evaluate the survivorship and radiographic outcomes of an acetabular reconstruction consisting of a polyethylene liner (semi-constrained) embedded in cement filling bone defect(s) reinforced with screws and/or plates for enhanced fixation (HiRISC).

Retrospective chart review of 59 consecutive acetabular reconstructions as described above performed by 4 surgeons in a single institution (10/18/2018-1/5/2023) was performed. After radiographs and operative reports were reviewed, cases were classified following the Paprosky classification for acetabular defects. Paprosky type 1 cases (n=26) were excluded, while types 2/3 (n=33) were included for analysis. Radiographic loosening was evaluated up to latest follow-up. Mean follow-up was: 487 days (range, 20–1,539 days).

Out of 33 cases, 2 (6.1%) cases were oncological (metastatic disease) and 22 (66.7%) had deep infection diagnosis (i.e., periprosthetic joint infection [PJI] or septic arthritis). In total, 7 (21.2%) reconstructions were performed on native acetabula (3 septic, 4 aseptic). At a mean follow-up of 1.3 years, 5 (15.2%) constructs were revised: 4 due to uncontrolled infection (spacer exchange) and 1 for instability. On follow-up radiographs, only 1 non-revised construct showed increased radiolucencies, but no obvious loosening. When compared to patients with non-revised constructs, those who underwent revision (n=5) were significantly younger (mean 73.8 vs. 60.6 years, p=0.040) and had higher body mass index (24.1 vs. 31.0 Kg/m², p=0.045), respectively. Sex, race, ethnicity, American-Society-of-Anesthesiologist classification, infection diagnosis status (septic/aseptic), and mean follow-up (449.3 vs. 695.6 days, respectively, p=0.189) were not significantly different between both groups.

HiRISC construct may be a viable short-term alternative to more expensive implants to treat large acetabular defects, particularly in the setting of PJI. Longer follow up is needed to establish long term survivorship.

Previous studies have reported excellent results with tapered, titanium alloy, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at minimum 25-year follow-up.

We reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component, the Mallory-Head Porous (MHP; Zimmer Biomet, Warsaw, IN). This device, marketed in the U.S. until December 2021, was essentially unchanged since its 1984 introduction, except the porous coating was continued circumferentially along the lateral aspect in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999 after the study period. Three hundred thirty-two patients (396 THA) had a minimum of 25-year follow-up. Mean age at surgery was 47.6 years (range, 21–70 years).

Mean follow-up in non-failed patients was 28.7 years (range, 25 to 37 years). There were 31 femoral revisions (7.8%): 9 infection, 3 failure of ingrowth, 5 aseptic loosening, 8 osteolysis revised well-fixed, 2 periprosthetic fracture, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with endpoint of stem revision for all causes was 94.8% (95% CI: ±0.9%) at 36.7 years, and survival with endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% CI: ±0.5) at 36.7 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently.

This tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth.

Dual mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a known rare complication of these implants and has reportedly decreased with modern implants. The purpose of this paper is to report the diagnosis and treatment of modern DM IPD.

1453 DM components were implanted between 2010 and 2021. 695 in primary and 758 in revision THA. 49 hips sustained a dislocation of the large head and 5 sustained an IPD at presentation. 6 additional IPD occurred at the time of reduction of large head. The average age was 64, 54% were female and the mean follow-up was three years. Of the 11 IPD, 8 had a history of instability, 5 had abductor insufficiency, 4 had prior lumbar fusion, and 3 were conversions from fracture.

The overall IPD incidence was 0.76%. Ten of the 11 DM IPD were missed at initial presentation or at the time of reduction, and all were discharged with presumed reduction. The mean time from IPD to surgical treatment was 3 weeks. One patient died with an IPD at 5 months. A DM head was reimplanted in six, two underwent revision of the acetabular component with exchange of DM head, and four were revised to a constrained liner. The re-revision rate was 55% at a mean 1.8 years. None of the patients who underwent cup revision required subsequent re-revision while half of the constrained liners and exchange of DM heads required re-revision.

The overall rate of DM dislocation or IPD is low. It is critical to identify an IPD on radiographs as it was almost universally missed at presentation or when it occurred iatrogenically. For patients presenting with IPD, the surgeon should consider acetabular revision and conversion to a constrained liner or a larger DM, with special attention to removing impinging structures that could increase the risk of re-dislocation.

Stem loosening can be associated with a wide spectrum of bone loss and deformity that represent key factors for choosing the most appropriate revision implant. The aim of this study was to evaluate the clinical outcomes and the survivorship of a consecutive series of THA revisions using a taper rectangular cementless stem for primary implants (Alloclassic® Zweymuller®, Zimmer Warsaw US) at medium-term follow-up.

We retrospectively evaluated 113 patients (115 revisions) who underwent femoral revision with Zweymuller stem with a preoperative Paprosky I (86) or II (29) defects from January 2011 to December 2020. The mean follow up was 6 years (2–10). The median age at time of surgery was 71(41–93) with 60 males and 53 females. Osteolysis/radiolucency were observed in the following Gruen zones: I (91), II (3), III (2), VII (15), V (3), VI (1). Clinical assessment was performed by means of Harris Hip Score (HHS) and Visual Analogic Scale (VAS), whereas for the radiological analysis we used conventional x-rays of the hips. The statistical analysis was performed using Graphpad Prism v5.0 and data distribution was assessed by Shapiro-Wilk test, and Wilcoxon matched paired test was used to test the differences between preoperative and postoperative score.

9 patients were lost to fu (deceased or not available), 104 (106 hips) were evaluated. The mean HHS and VAS significantly improved at final follow-up, going from 33,84 and 5,78 preoperatively to 66,42 and 2,05 postoperatively, respectively. 28 patients (25%) showed unprogressive radiolucent lines in Gruen zones 1 and 7 with no other radiological nor clinical signs of loosening. One patient suffered from recurrence of the infection. The survivorship with stem revision as endpoint was 100%.

Alloclassic Zweymüller primary stem showed good medium-term results and survival rate in revision THA for aseptic loosening and second stages of two stage revisions.

Patients with a high comorbidity burden (high-risk) can achieve similar improvements in quality of life compared to low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences THA outcomes in high-risk patients has not been investigated. This study aimed to compare complication rates and implant survivorship in high-risk patients operated on by high volume (HV) and non-HV THA surgeons.

Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologist Classification of 3 or 4 undergoing primary, elective THA between 2013 and 2021 were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Ninety day readmissions and revisions were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.

Years of experience were comparable between Non-HV and HV surgeons (p=0.733). The HV group had significantly shorter surgical times (p<0.001), and shorter length of stay (p=0.009) compared to the Non-HV group. The HV group also had significantly fewer 90-day readmissions (p=0.030), all-cause revisions (p=0.023) and septic revisions (p=0.020) compared to the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p=0.023) and septic revision (p=0.020) compared to the non-HV group.

High-risk THA patients have fewer 90-day readmissions, all-cause revisions, septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a high comorbidity burden may benefit from referral to high-volume surgeons to reduce procedural risk and improve postoperative outcomes.

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery.

We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip.

Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially.

The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller.

By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm).

At the end of 2018, the NZ Joint Registry introduced a “Surgeon Outlier” policy, whereby each year, if an individual surgeons’ lower 95% confidence interval of their revision rate, measured in revision/100 component years(r/ocys), was above the NZ mean (0.71 r/ocys), that surgeon was required to audit their results with a nominated peer. This study investigates whether outlier surgeons also have high early (1 month and 1 year) revision rates.

In 2018, 236 surgeons performed 9,186 total hip arthroplasties in NZ. At the end of 2018, 11 surgeons received notification they were outliers. Results from all surgeons for years 2016, 2017 and 2018 were combined to form the first (pre-notification) time interval, and results from years 2019, 2020 and 2021 were combined to form the second time interval (post-notification). Outlier surgeons performed 2001 total hip replacements in the first time interval and 1947 hips in the second. Early revision rates (1 month and 1 year) of both outlier and nonoutlier surgeons for both time intervals were analysed.

Non-outlier surgeons had a consistent mean early revision rate of 0.75% at one month and 1.6% at one year for both time intervals. The 11 outlier surgeons had a higher earlier revision rate of 1.35% at one month and 2.45% at one year for the pre-notification time interval. These values reduced for the post-notification time interval to a revision rate of 1.23% for one month and 2.36% for one year.

Poor joint registry results of individual surgeons are often attributed to a poor choice of prosthesis. This study shows early revision rates of outlier surgeons, where prosthesis selection has minimal influence, are also high.

A slight improvement in early revision rates of outlier surgeons since introduction of the policy shows it is working.

Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF).

This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel.

Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA.

This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique.

Young patients undergoing THA or hip used. HOS and iHOT33 have demonstrated to be useful in hip preservation surgery but never used in THA.

The aim of the study was to evaluate long-term clinical outcomes with HOS and iHOT33 in hip arthroscopy and THA

We conducted a retrospective study with prospective data collection of 118 consecutive young patients (<65 y.o.) between 2008 to 2012 who underwent hip arthroscopy or THA. The mean follow-up was 12.05 years. All surgeries were done by the same senior surgeon. PROMs used were iHOT-33 and HOS preoperatively, at one year and 10 years. SPSS Statistics Grad Pack 28.0 software was used for statistical analysis

Arthroscopy Group (57 patients): Mean age 35.36 years. 55.93% were male. iHOT33 mean differential improvement was 24.43 at 1 year, 70,17% exceed MCID and 49,1% SCB. HOS mean differential improvement was 16.26 at one year. 54,38 % patients exceed MCID and 49,36% SCB. At 10 years, iHOT33 mean differential improvement was 14,36 and 12.56 for HOS. Regarding complications, 3 patients underwent THA (5.26%) and 10 (17.54%) continued with groin pain.

THA Group (61 patients): Mean age 52,54 years. 55.73% were male. Cementless THA was used in all patients with ceramic on ceramic used in 77%. iHOT33 mean differential improvement was 41,57 at 1 year. 95,08% patients exceed MCID and 85,25% SCB. HOS mean differential improvement was 16.57 points at one year. 85,25% patients exceed MCID and 81,97% SCB. At 10 years, iHOT33 mean differential improvement was 20,15 and 14.12 for HOS. Regarding complications, 1 patient underwent DAIR for infection (1.64%) and 1 dislocation with close reduction (1.64%).

iHOT33 or HOS scores should be considered to be used in young active patients after hip preserving surgery or THA, with more predictable results at long-term in THA group.

3D printing is rapidly being adopted by manufacturers to produce orthopaedic implants. There is a risk however of structural defects which may impact mechanical integrity. There are also no established standards to guide the design of bone-facing porous structures, meaning that manufacturers may employ different approaches to this. Characterisation of these variables in final-production implants will help understanding of the impact of these on their clinical performance.

We analysed 12 unused, final-production custom-made 3D printed acetabular cups that had been produced by 6 orthopaedic manufacturers. We performed high resolution micro-CT imaging of each cup to characterise the morphometric features of the porous layers: (1) the level of porosity, (2) pore size, (3) thickness of porous struts and (4) the depth of the porous layers. We then examined the internal cup structures to identify the presence of any defects and to characterise: (1) their total number, (2) volume, (3) sphericity, (4) size and (5) location.

There was a variability between designs in the level of porosity (34% to 85%), pore size (0.74 to 1.87mm), strut thickness (0.28 to 0.65mm), and porous layer depth (0.57 to 11.51mm). One manufacturer printed different porous structures between the cup body and flanges; another manufacturer printed two differing porous regions within the cup body.

5 cups contained a median (range) of 90 (58–101) defects. The median defect volume was 5.17 (1.05–17.33) mm3. The median defect sphericity and size were 0.47 (0.19–0.65) and 0.64 (0.27–8.82) mm respectively. The defects were predominantly located adjacent to screw holes, within flanges and at the transition between the flange and main cup body; these were between 0.17 and 4.66mm from the cup surfaces.

There is a wide variability between manufacturers in the porous titanium structures they 3D print. The size, shape and location of the structural defects identified are such that there may be an increased risk of crack initiation from them, potentially leading to a fracture. Regulators, surgeons, and manufacturers should be aware of this variability in final print quality.

Clinical commissioning groups (CCG) have been replaced with ICBs that will bring together NHS and social care for the local population. ICBs are allocating contracts for long waiters for total hip replacements (THR) to hospitals that have achieved pre-covid volumes of THR, THR volumes undertaken by hospitals in 2022 should be at 2019 levels or more.

Purpose of this study was to identify whether NHS hospitals in England are at a disadvantage in procuring ICB contracts for THR.

THR volumes for NHS and independent sector (IND) hospitals from January 2012 to November 2022 were identified via National Joint Registry. Regional and national trend for THR volumes were identified for both NHS and IND hospitals using linear regression analysis.

Trends of THR for NHS hospitals showed either stagnation or reduction in volume from 2014–2019. In 2022, nationally THR volume of NHS was 70% of 2019 (Figure 1). Trend of THR volume for IND hospitals nationally was a strong uptrend from 2012 to 2022 with a break only in 2020 due to COVID pandemic (Figure 2). Since the pandemic IND have overtaken NHS hospitals in volumes of THR undertaken. Similar picture of trends evolves when THR trends were assessed on a region by region basis.

With NHS hospitals not back to pre-pandemic THR volumes, IND hospitals have a distinct advantage in securing more contracts via ICB. This in turn puts NHS hospitals at risk of taking on more complex and medically unwell patients potentially worsening NJR outcomes for NHS hospitals.

The reasons for the lag in NHS hospitals’ THR volumes are multifactorial, not limited to continued bed pressures, increased emergency and unplanned admissions, staff shortages and sickness, pension taxations preventing doctors from undertaking more THR. However, lack of access to contracts from ICB will put NHS hospitals at huge financial and existential risk for elective care.

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