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.
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. A retrospective chart review was conducted to identify patients undergoing primary total hip arthroplasty (THA). Plain AP pelvic radiographs were reviewed to document the morphological characteristic of osteoarthritic hips. Lateral spine-pelvis-hip sitting and standing plain radiographs were used to measure sacral slope (SS) and pelvic femoral angle (PFA) in each position. Lumbar disc spaces were measured to determine the presence of DDD. The difference between sitting and standing SS and PFA were calculated to quantify spinopelvic motion (ΔSS) and hip motion (ΔPFA), respectively. Univariate analysis and Pearson correlation were used to identify morphological hip characteristics associated with changes in spinopelvic motion.Aims
Methods
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. We identified 33 patients who underwent treatment for PJIs of the hip between January 2010 and December 2019 using our institutional joint registry. Mean age was 82 years (80 to 90), with 19 females (57%) and a mean BMI of 26 kg/m2 (17 to 41). Mean American Society of Anesthesiologists (ASA) grade was 3 (1 to 4) and mean Charlson Comorbidity Index was 6 (4 to 10). Leading pathogens included coagulase-negative Staphylococci (45%) and Aims
Methods
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). A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples Aims
Methods
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. In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound.Aims
Methods
Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size.Aims
Methods
Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty. Between November 2000 and December 2016, we retrospectively evaluated 144 consecutive hip procedures in 122 patients a minimum of five years after undergoing modified Spitzy shelf acetabuloplasty for acetabular dysplasia including osteoarthritis (OA). Our follow-up rate was 92%. The mean age at time of surgery was 37 years (13 to 58), with a mean follow-up of 11 years (5 to 21). Advanced OA (Tönnis grade ≥ 2) was present preoperatively in 16 hips (11%). The preoperative lateral centre-edge angle ranged from -28° to 25°. Survival was determined by Kaplan-Meier analysis, using conversions to total hip arthroplasty as the endpoint. Risk factors for joint space narrowing less than 2 mm were analyzed using a Cox proportional hazards model.Aims
Methods
Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA). This study is a secondary analysis of patients aged 50 years or older with a displaced femoral neck fracture who were enrolled in the HEALTH trial and underwent monopolar and bipolar HA. Scores from the Western Ontario and McMaster University Arthritis Index (WOMAC) and 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and (MCS) were compared between the two HA groups using a propensity score-weighted analysis.Aims
Methods
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. We describe the survival, radiological, and functional outcomes of 33 patients (38 THAs) at a mean follow-up of 27 years (25 to 32) between 1988 and 2018.Aims
Methods
Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design. Patients with end-stage osteoarthritis were enrolled in a prospective cohort at a single centre. The cohort consisted of 11 females and 11 males with mean age of 70.6 years (SD 3.5) and BMI of 31.0 kg/m2 (SD 5.7). Implant fixation was evaluated using RSA as well as Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score, Oxford Hip Score, Hip disability and Osteoarthritis Outcome Score, 38-item Short Form survey, and EuroQol five-dimension health questionnaire scores at two-year follow-up. At least one acetabular screw was used in all cases. RSA markers were inserted into the innominate bone and proximal femur with imaging at six weeks (baseline) and six, 12, and 24 months. Independent-samples Aims
Methods
Refobacin Bone Cement R and Palacos Overall, 75 patients were included in the study and 71 were available at two years postoperatively. Prior to surgery, they were randomized to one of the three combinations studied: Palacos cement with use of the Optivac mixing system, Refobacin with use of the Optivac system, and Refobacin with use of the Optipac system. Cemented MS30 stems and cemented Exceed acetabular components were used in all hips. Postoperative radiographs were used to assess the quality of the cement mantle according to Barrack et al, and the position and migration of the femoral stem. Harris Hip Score, Oxford Hip Score, Forgotten Joint Score, and University of California, Los Angeles Activity Scale were collected.Aims
Methods
The risk factors for abnormal spinopelvic mobility (SPM), defined as an anterior rotation of the spinopelvic tilt (∆SPT) ≥ 20° in a flexed-seated position, have been described. The implication of pelvic incidence (PI) is unclear, and the concept of lumbar lordosis (LL) based on anatomical limits may be erroneous. The distribution of LL, including a unusual shape in patients with a high lordosis, a low pelvic incidence, and an anteverted pelvis seems more relevant. The clinical data of 311 consecutive patients who underwent total hip arthroplasty was retrospectively analyzed. We analyzed the different types of lumbar shapes that can present in patients to identify their potential associations with abnormal pelvic mobility, and we analyzed the potential risk factors associated with a ∆SPT ≥ 20° in the overall population.Aims
Methods
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. The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time.Aims
Methods
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. We reviewed 103 patients with DDH successfully treated by CR and spica casting in a single institution between January 2016 and December 2020. MRI was routinely performed immediately after CR and at the end of each cast. Using MRI, we described the labrum-acetabular cartilage complex (LACC) morphology, and measured the femoral head to triradiate cartilage distance (FTD) on the midcoronal section. A total of 13 hips with initial complete reduction (i.e. FTD < 1 mm) and ten hips with incomplete MRI follow-up were excluded. A total of 86 patients (92 hips) with a FTD > 1 mm were included in the analysis.Aims
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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. A consecutive series of 45 (2014 to 2019) PPRs for Paprosky III defects at rTHA were analyzed comparing the preoperative planning CT scans used to manufacture the implants with postoperative CT scans and radiographs. The anteversion (AV), inclination (IC), deviation from the preoperatively planned implant position, and deviation of the centre of rotation (COR) were explored. Early postoperative complications were recorded, and factors for malpositioning were sought. The mean follow-up was 30 months (SD 19; 6 to 74), with four patients lost to follow-up.Aims
Methods
Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories. This retrospective cohort study analyzed THA patients at a large academic centre (NYU Langone Orthopedic Hospital, New York, USA) from January 2018 to January 2023, who completed the Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity questionnaires, collected preoperatively at one-, three-, six-, 12-, and 24-month follow-up times. Growth mixture modelling (GMM) was used to model the trajectories. Optimal model fit was determined by Bayesian information criterion (BIC), Vuong-Lo-Mendell-Rubin likelihood ratio test (VLMR-LRT), posterior probabilities, and entropy values. Association between trajectory groups and patient characteristics were measured by multinomial logistic regression using the three-step approach.Aims
Methods
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. Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 September 1999 and 31 December 2020 who underwent hemiarthroplasty for the treatment of a hip fracture with the following implants were included: a cemented monoblock Exeter Trauma Stem (ETS), cemented Exeter V40 with a bipolar head, a monoblock Thompsons prosthesis (Cobalt/Chromium or Titanium), and an Exeter V40 with a Unitrax head. Overall and age-defined cumulative revision rates were compared over the ten years following surgery.Aims
Methods
A significant reduction in wear at five and ten years was previously reported when comparing Durasul highly cross-linked polyethylene with nitrogen-sterilized Sulene polyethylene in total hip arthroplasty (THA). We investigated whether the improvement observed at the earlier follow-up continued, resulting in decreased osteolysis and revision surgery rates over the second decade. Between January 1999 and December 2001, 90 patients underwent surgery using the same acetabular and femoral components with a 28 mm metallic femoral head and either a Durasul or Sulene liner. A total of 66 hips of this prospective randomized study were available for a minimum follow-up of 20 years. The linear femoral head penetration rate was measured at six weeks, one year, and annually thereafter, using the Dorr method on digitized radiographs with a software package.Aims
Methods
This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years’ clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery.Aims
Methods
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. We identified 64 patients (65 hips) who had a single-design cemented DM cup cemented into an uncemented acetabular shell during revision THA between 2018 and 2020 at our institution. Cups were cemented into either uncemented cups designed for liner cementing (n = 48; 74%) or retained (n = 17; 26%) acetabular components. Median outer head diameter was 42 mm. Mean age was 69 years (SD 11), mean BMI was 32 kg/m2 (SD 8), and 52% (n = 34) were female. Survival was assessed using Kaplan-Meier methods. Mean follow-up was two years (SD 0.97).Aims
Methods
This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice. National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man were received for 84,816 RHAs and 818,979 PHAs recorded between April 2011 and December 2019. RHA data comprised all revision procedures, including first-time revisions of PHA and any subsequent re-revisions recorded in public and private healthcare organizations. Annual procedure volumes undertaken by the responsible consultant surgeon in the 12 months prior to every index procedure were determined. We identified a cohort of ‘new’ HA consultants who commenced practice from 2012 and describe their rate of accrual of PHA and RHA experience.Aims
Methods
Pelvic tilt is believed to affect the symptomology of osteoarthritis (OA) of the hip by alterations in joint movement, dysplasia of the hip by modification of acetabular cover, and femoroacetabular impingement by influencing the impingement-free range of motion. While the apparent role of pelvic tilt in hip pathology has been reported, the exact effects of many forms of treatment on pelvic tilt are unknown. The primary aim of this study was to investigate the effects of surgery on pelvic tilt in these three groups of patients. The demographic, radiological, and outcome data for all patients operated on by the senior author between October 2016 and January 2020 were identified from a prospective registry, and all those who underwent surgery with a primary diagnosis of OA, dysplasia, or femoroacetabular impingement were considered for inclusion. Pelvic tilt was assessed on anteroposterior (AP) standing radiographs using the pre- and postoperative pubic symphysis to sacroiliac joint (PS-SI) distance, and the outcomes were assessed with the Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and Harris Hip Score (HHS).Aims
Methods
Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components. Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels.Aims
Methods
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. A multicentre observational cohort study in Australia between February 2017 and March 2021 included consecutive patients undergoing acetabular reconstruction with CTACs in rTHA (Paprosky 3A/3B defects) or tumour resection (including Enneking P2 peri-acetabular area). Of 103 eligible patients (104 hips), 34 patients (35 hips) were analyzed.Aims
Methods
Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA. This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery.Aims
Methods
The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate. This retrospective analysis identified 267 hips from 224 patients who underwent an hip resurfacing arthroplasty (HRA) from a single fellowship-trained surgeon using the direct lateral approach between 2007 and 2019. Inclusion criteria was minimum two-year follow-up, and age younger than 40 years. Patients were followed using a prospectively maintained institutional database.Aims
Methods
Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures. A retrospective cohort analysis of young adults (aged < 50 years) undergoing THA between May 2018 and May 2023 in a single tertiary centre was undertaken. Median follow-up was 31 months (12 to 61). Oxford Hip Score (OHS) and focus group-designed questionnaires were distributed. Searches identified 244 cases in 225 patients. Those aged aged under 30 years represented 22.7% of the cohort. Developmental dysplasia of the hip (50; 45.5%) and Perthes’ disease (15; 13.6%) were the commonest indications for THA.Aims
Methods
Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's Aims
Methods
Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error. A total of 356 patients undergoing primary THA were prospectively enrolled from November 2016 to March 2018. Clinically relevant error using the CAS system was defined as a difference of > 5° between CAS and 3D radiological reconstruction measurements for acetabular component inclination and anteversion. Univariate and multiple logistic regression analyses were conducted to determine whether hypermobile (Aims
Methods
BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems. A total of 53 patients were randomized to be treated using Bi-Metric cementless femoral stems with either only a porous titanium plasma-sprayed coating (P group) or a porous titanium plasma-sprayed coating with an additional BoneMaster coating (PBM group). The patients were examined with radiostereometry until five years after surgery.Aims
Methods
This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures. From our electronic database of 751 hip arthroplasty procedures, 221 patients were included. Patients were excluded if they had revision surgery, an alternative hip procedure, or incomplete data either preoperatively or at one-year follow-up. Included patients had a mean age of 59.4 years (SD 11.3) and 54.3% were male, incorporating 117 primary total hip and 104 hip resurfacing arthroplasty operations. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and the MET were recorded preoperatively and at one-year follow-up. The distribution was examined reporting the presence of ceiling and floor effects. Validity was assessed correlating the MET with the other scores using Spearman’s rank correlation coefficient and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analyzed by age, sex, BMI, and preoperative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS.Aims
Methods
Perthes’ disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes’ disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes’ disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample? The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6).Aims
Methods
Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems. We conducted biomechanical testing of bone analogues using six cemented stems of three different types: collarless polished tapered (CPT) stem, Versys Advocate (Versys) stem, and Charnley-Marcel-Kerboull (CMK) stem. Experienced surgeons implanted each of these types of stems into six bone analogues, and the analogues were compressed and internally rotated until failure. Torque to fracture and fracture type were recorded. We also measured surface strain distribution using triaxial rosettes.Aims
Methods
Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups. We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA.Aims
Methods
The aim of this study was to compare the mid-term patient-reported outcome, bone remodelling, and migration of a short stem (Collum Femoris Preserving; CFP) with a conventional uncemented stem (Corail). Of 81 patients who were initially enrolled, 71 were available at five years’ follow-up. The outcomes at two years have previously been reported. The primary outcome measure was the clinical result assessed using the Oxford Hip Score (OHS). Secondary outcomes were the migration of the stem, measured using radiostereometric analysis (RSA), change of bone mineral density (BMD) around the stem, the development of radiolucent lines, and additional patient-reported outcome measures (PROMs).Aims
Methods
The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds.Aims
Methods
The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes. We retrospectively identified 256 primary total hip arthroplasties (THAs) that included a DM component (144 Stryker MDM and 112 Zimmer-Biomet G7) in 233 patients, performed between January 2012 and December 2019. Postoperative radiographs were reviewed independently for malseating of the liner by five reviewers. The mean age of the patients at the time of THA was 66 years (18 to 93), 166 (65%) were female, and the mean BMI was 30 kg/m2 (17 to 57). The mean follow-up was 3.5 years (2.0 to 9.2).Aims
Methods
The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells. HIPGEN is a multicentre, multinational, randomized, double-blind, placebo-controlled trial. A total of 240 patients aged 60 to 90 years with low-energy femoral neck fractures (FNF) will be allocated to two arms and receive an intramuscular injection of either 150 × 106 PLX-PAD cells or placebo into the medial gluteal muscle after direct lateral implantation of total or hemi hip arthroplasty. Patients will be followed for two years. The primary endpoint is the Short Physical Performance Battery (SPPB) at week 26. Secondary and exploratory endpoints include morphological parameters (lean body mass), functional parameters (abduction and handgrip strength, symmetry in gait, weightbearing), all-cause mortality rate and patient-reported outcome measures (Lower Limb Measure, EuroQol five-dimension questionnaire). Immunological biomarker and in vitro studies will be performed to analyze the PLX-PAD mechanism of action. A sample size of 240 subjects was calculated providing 88% power for the detection of a 1 SPPB point treatment effect for a two-sided test with an α level of 5%.Aims
Methods
This study aims to answer the following questions in patients with hip osteoarthritis (OA) who underwent total hip arthroplasty (THA): are patient-reported outcome measures (PROMs) affected by the location of the maximum severity of pain?; are PROMs affected by the presence of non-groin pain?; are PROMs affected by the severity of pain?; and are PROMs affected by the number of pain locations? We reviewed 336 hips (305 patients) treated with THA for hip OA from December 2016 to November 2019 using pain location/severity questionnaires, modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), international Hip Outcome Tool (iHOT-12) score, and radiological analysis. Descriptive statistics, analysis of covariance (ANCOVA), and Spearman partial correlation coefficients were used.Aims
Methods
Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented.Aims
Methods
The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA. We retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value.Aims
Methods
This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum. Data on adult patients who underwent arthroscopic labral debridement or repair between 1 January 2012 and 31 July 2019 were extracted from the UK Non-Arthroplasty Hip Registry. Patients who underwent microfracture, osteophyte excision, or a concurrent extra-articular procedure were excluded. The EuroQol five-dimension (EQ-5D) and International Hip Outcome Tool 12 (iHOT-12) questionnaires were collected preoperatively and at six and 12 months post-operatively. Due to concerns over differential questionnaire non-response between the two groups, a combination of random sampling, propensity score matching, and pooled multivariable linear regression models were employed to compare iHOT-12 improvement.Aims
Methods
Young adult hip pathology commonly affects patients of reproductive age. The extent to which hip arthroscopy (HA) treatments influence sexual function is not well described and limited to small cohorts. This study aims to describe trends in self-reported reported sexual function before and after HA. Adult (≥18 years) patients who underwent HA between 1st January 2012 and 31st October 2020 were extracted from the UK Non-Arthroplasty Hip Registry. International Hip Outcome Tool 12 (iHOT-12) questionnaires were collected pre-operatively and at 6 and 12 months. Patients are first asked if ‘questions about sexual activity are relevant to them’. The iHOT-12 then asks asking patients to quantify ‘how much trouble they experience with sexual activity because of their hip?’ with responses converted to a continuous scale (0–100) to measure function. Chi-squared and t-tests were used to compare categorical and continuous variables respectively. Of 7639 procedures (59% female, mean age 36.5 years (SD 11)), 91% (5616 of 6151 respondants) indicated pre-operatively that questions about sexual activity were relevant to them (male 93%, female 90%, p < 0.001). Overall, mean pre-operative sexual function increased from 42.0 (95%CI 41.2 to 42.8, n=5267) to 61.8 (60.6 to 63.1, n=2393) at 6 months, and 62.1 (60.8 to 63.5, n=2246) at 12 months post-operatively. At 12 months, both sexes saw significant improvement in their pre-operative sexual function scores (p<0.0001). Males started from significantly higher baseline sexual function (53.3 vs 34.2) and achieved higher scores by 12 months (68.8 vs 58.0) compared to female patients. There was no significant difference in pre- or post-operative scores when comparing younger (<40 years) and older (>40 years). Most patients can expect to experience improvement in their sexual function following hip arthroscopy, regardless of sex or age group.
The 2020 London International Hamstring Consensus meeting was convened to improve our understanding and treatment of hamstring injuries. The multidisciplinary consensus panel included 14 International specialists on the management of hamstring injuries. The Delphi consensus process consisted of two rounds of surveys which were completed by 19 surgeons from a total of 106 participants. Consensus on individual statements was regarded as over 70% agreement between panel members. The consensus group agreed that the indications for operative intervention included the following: gapping at the zone of injury (86.9%); high functional demands of the patient (86.7%); symptomatic displaced bony avulsions (74.7%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (71.4%). Panel members agreed that surgical intervention had the capacity to restore anatomy and function, while reducing the risk of injury recurrence (86.7%). The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help to further standardise the treatment of hamstring injuries and facilitate decision-making in the surgical treatment of these injuries.
Periprosthetic femoral fracture (PFF) incidence following hip replacement surgery continues to rise. There is a national drive to centralise PFF treatment within specialist centres to improve clinical outcomes and cost-effectiveness. The financial implications of treating PFFs must be analysed to guide allocation of funding. Data were collected for 129 PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by the Patient Level Information and Costing Systems (PLICS) team. Primary outcomes were cost, revenue and margin for each PFF. Additional data were collected on length of stay (LOS), critical care requirements and clinical outcomes. Statistical comparisons were made between treatment type (fixation vs revision). Significance was set to p<0.05. Across the entire cohort, total cost was £2,389,901, total revenue was £1,695,435 and total loss was £694,481. Highest costs were ward stay (£714,591), theatre utilisation (£382,625), and overheads (£249,110). Median cost was £15,863 (IQR, £11,092-£22,221), median revenue was £11,305 (IQR, £7,147-£15,222) and median loss was £3,795 (IQR, £605-£8687). Median LOS was 21 days (IQR 13–34) and 28.7% patients required critical care admission. Ninety-six patients were treated operatively with either fixation (n=53) or revision (n=43). Median operating time was lower for fixation versus revision (132 [IQR, 115–185] vs 201 [IQR, 159–229] minutes, p=0.001). Median cost (£17,455 [IQR, £13,095-£22,824] vs £17,399 [£13,394-£23,404]) and median loss (£5,774 [IQR, £2,092-£10,472] vs £3,860 [IQR, £96-£7,601]) were similar for fixation and revision (p=0.99 and p=0.18, respectively). Median revenue was greater for revision versus fixation (£13,925 [IQR, £11,294-£17,037] vs £12,160 [IQR, £8,486-£14,390], p=0.02). There was no difference in LOS (21 [13–34] vs 21 [14–30] days, p=0.94), critical care requirements (20 [37.7%] vs 11 [25.6%], p=0.30), reoperations (3 [5.7%] vs 6 [14.0%], p=0.29], local complications (8 [15.1%) vs 12 [27.9%], p=0.20) or systemic complications (11 [20.8%] vs 11 [25.6%], p=0.75) between fixation and revision. PFF treatment costs are high with inadequate reimbursement through tariff. Work is needed to address this disparity and reduce costs associated with LOS, theatre utilisation and implants. Treatment cost should not be used when deciding between fixation and revision surgery.
Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health (DoH) in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA). Waiting list information was obtained via a Freedom of Information request to the DoH (May 2021) and National Joint Registry data was used to determine baseline operative numbers. Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to determine the time to clear the waiting lists for THA using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections. As of May 2021, there were 3,757 patients awaiting primary THA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum added to the waiting list for primary THA and there were a mean 1,624 primary THAs performed per annum. The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre COVID-19 pandemic capacity and will be achieved in 2030 if capacity is 170%. Surgical capacity must exceed pre-Covid capacity by at least 30% to meet ongoing demand. THA capacity was significantly reduced following resumption of elective orthopaedics post-COVID-19 (22% of pre-COVID-19 capacity – 355 THAs/annum post-COVID-19 versus 1,624/annum pre-COVID-19). This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip arthroplasty. Waiting times for THA surgery in the NHS in Northern Ireland are likely to remain greater than 52 weeks for most of this decade.
Disease specific or generic Patient Reported Outcome Measures (PROMs) can be completed by patients using paper and postal services (pPROMS) or via computer, tablet or smartphone (ePROMs) or by hybrid data collection, which uses both paper and electronic questionnaires. We have investigated whether there are differences in scores depending on the method of PROMs acquisition for the Oxford Hip Score (OHS) and the EQ-5D scores, at one and two years post operatively. Patients for this study were identified retrospectively from a prospectively compiled arthroplasty database held at the study centre. Patient demographics, mode of preferred data collection and pre- and post-operative PROMs for Total Hip Replacements (THRs) performed at this centre between 1st January 2018 and 31st December 2018 were collected. During the study period, 1494 patients underwent THRs and had complete one and two-year PROMs data available for analysis. All pre-operative scores were obtained by pPROMS. The average OHS and EQ-5D pre-operatively scores were 19.51 and 0.36 respectively. 72.02% of the patients consented to undertake post-operative questionnaires using ePROMs. The remaining 27.98% opted for pPROMS. The one and two-year OHS for ePROMS patients increased to 41.31 and 42.14 while the OHS scores for pPROMS patients were 39.80 and 39.83. At the one and two-year post-operative time intervals, a Mann-Whitney test showed statistical significance between the modes of administration for OHS (P-Value =0.044 and 0.01 respectively). The one and two-year EQ-5D for ePROMS patients increased to 0.83 and 0.84 while the EQ-5D scores for pPROMS patients were 0.79 and 0.81. The P-Value for Mann-Whitney tests comparing the modes of administration for EQ-5D were 0.13 and 0.07 respectively. Within Orthopaedics, PROMs have become the most widely used instrument to assess patients’ subjective outcomes. However, there is no agreed mode of PROMs data acquisition. While we have demonstrated an apparent difference in scores depending on the mode of administration, further work is required to establish the influence of potentially confounding factors such as patient age, gender and familiarity with computer technology.
The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9th February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of bias only. For revision hip arthroplasty patients receiving ICS, 37.07% required ABT with a mean transfusion of 1.92 units or 385ml per patient. For patients treated without ICS, 64.58% required ABT with a mean transfusion of 4.02 units or 803ml per patient. This difference achieved statistical significance (p < 0.05). This study has demonstrated a significant reduction in the need for allogenic blood transfusion associated with intra-operative cell salvage use among patients undergoing revision hip arthroplasty. This study therefore supports the routine use of ICS in this patient group. However, a major limitation is the lack of clinical outcomes reported by the available studies. Further research is required to determine whether this effect is associated with sub-groups of revision arthroplasty procedure, and whether ICS impacts clinical outcomes such as length of stay, rehabilitation progress and mortality.
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 standard deviation for the change score for the entire population was 9.93, which can be interpreted as the RMSE that would be achieved for a model that gives the same estimation for all patients regardless of the covariates. However, most of the variation in the postoperative OHS/OKS change score is not captured by the models, confirming the importance of accurate uncertainty estimation. 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.
The 10 year survivorship of THR is generally over 95%. However, the incidence of revision is usually higher in year one. The most common reason being dislocation which at least in part is driven by inadequate range of motion (ROM) leading to impingement, subluxation and ultimately dislocation which is more frequently posterior. ROM is affected by patient activity, bone and component geometry, and component placement. To reduce the incidence of dislocation, supported by registry data, there has been an increase in the use of so-called ‘lipped’ liners. Whilst this increases joint stability, the theoretical ROM is reduced. The aim of this study was to investigate the effect of lip placement on impingement. A rigid body geometric model was incorporated into a CT scan hemi-pelvis and femur, with a clinically available THR virtually implanted. Kinematic activity data associated with dislocation was applied, comprising of five posterior and two anterior dislocation risk activities, resulting from anterior and posterior impingement respectively. Cup inclination and anteversion was varied (30°-70°, 0°-50° respectively) to simulate extremes of clinical outcomes. The apex position of a ‘lipped’ liner was rotated from the superior position, anteriorly and posteriorly in steps of 45°. Incidence and location of implant and bone impingement was recorded in 5346 cases generated. A liner with the lip placed superior increased the occurrence of implant-implant impingement compared with a neutral liner. Rotation of the lip from superior reduced this incidence. This effect was more marked with posterior rotation which after 90° reduced anterior impingement to levels similar to a neutral liner. Complete inversion of the lipped liner reduced impingement, but this and anterior rotation both negate its function – additional stability. This study comprises one bone geometry and component design and one set of activity profiles. Nevertheless, it indicates that appropriate lip placement can minimise the likelihood of impingement for a range of daily activities whilst still providing additional joint stability.
