There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Objectives

The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient’s recollection of their own preoperative OHS and OKS one year following surgery.

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

Aims

Risk of revision following total knee arthroplasty (TKA) is higher in patients under 55 years, but little data are reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction in these patients.

Risk of revision following total knee replacement is relatively high in patients under 55 years of age, but little is reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction following TKR in patients younger than 55 years of age.

We assessed 177 TKRs (157 consecutive patients) from 2008 to 2013. Data was collected on age, sex, implant, indication, BMI, social deprivation, range of motion, and prior knee surgery in addition to Oxford Knee Score (OKS) and SF-12 score. Postoperative data included knee range of motion, complications, and OKS, SF-12 score and satisfaction measures at one year.

Overall, 24.9% of patients (44/177) were unsure or dissatisfied with their TKR. Significant predictors of dissatisfaction on univariable analysis (p<0.05) included: Kellgren-Lawrence grade 1/2 osteoarthritis; indication; poor preoperative OKS; postoperative complications; and poor improvements in OKS and pain component score (PCS) of the SF-12. Odds ratios for dissatisfaction by indication compared to primary OA: OA with previous meniscectomy 2.86; OA in multiply operated knee 2.94; OA with other knee surgery 1.7; OA with BMI>40kgm-2 2; OA post-fracture 3.3; and inflammatory arthropathy 0.23. Multivariable analysis showed poor preoperative OKS, poor improvement in OKS and postoperative stiffness, particularly flexion of <90°, independently predicted dissatisfaction (p<0.005).

Patients coming to TKR when under 55 years of age differ from the ‘average’ arthroplasty population, often having complex knee histories and indications for surgery, and an elevated risk of dissatisfaction.

Total knee arthroplasty (TKA) is an established and successful procedure. However, the design of prostheses continues to be modified in an attempt to optimise the functional outcome of the patient.

The aim of this study was to determine if patient outcome after TKA was influenced by the design of the prosthesis used.

A total of 212 patients (mean age 69; 43 to 92; 131 female (62%), 81 male (32%)) were enrolled in a single centre double-blind trial and randomised to receive either a Kinemax (group 1) or a Triathlon (group 2) TKA.

Patients were assessed pre-operatively, at six weeks, six months, one year and three years after surgery. The outcome assessments used were the Oxford Knee Score; range of movement; pain numerical rating scales; lower limb power output; timed functional assessment battery and a satisfaction survey. Data were assessed incorporating change over all assessment time points, using repeated measures analysis of variance longitudinal mixed models. Implant group 2 showed a significantly greater range of movement (p = 0.009), greater lower limb power output (p = 0.026) and reduced report of ‘worst daily pain’ (p = 0.003) over the three years of follow-up. Differences in Oxford Knee Score (p = 0.09), report of ‘average daily pain’ (p = 0.57) and timed functional performance tasks (p = 0.23) did not reach statistical significance. Satisfaction with outcome was significantly better in group 2 (p = 0.001).

These results suggest that patient outcome after TKA can be influenced by the prosthesis used.

Cite this article: Bone Joint J 2015;97-B:64–70.

We define the medium-term outcomes following total hip replacement (THR) for hip fracture. There is currently no information regarding longer term clinical and patient reported outcomes in this group of patients selected in accordance with national guidelines.

We prospectively identified patients who underwent THR for a displaced hip fracture over a three year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford hip score, Short-form 12(SF-12) questionnaire and satisfaction questionnaire.

We identified 128 patients. Mean follow up was at 5.4 years with a mean age of 76.5 years. 21 patients (16%) had died, 12 patients (9%) had developed dementia and 3 patients had no contact details, leaving a study group of 92 patients. 74 patients(80%) responded. Patients reported excellent functional outcomes and satisfaction at 5 years (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2 year follow up, there was no statistically significant change in outcome.

Medium-term outcomes for THR after hip fracture are excellent and the early proven benefits of this surgery are sustained. Mortality rates are equivalent to elective THR registry data and significantly lower than overall mortality rates following hip fracture. Our data validates the selection process detailed in national guidelines and confirms the low complication rate. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

We report the largest series of periprosthetic fractures in the literature, describing the changing epidemiology and predictors of outcome.

A retrospective search of prospectively compiled trauma and elective electronic databases identified 630 periprosthetic fractures presenting to the study centre between 1995 and 2010. Patient demographics, comorbidities, socioeconomic status, mechanism of injury, fracture type, classification, method of fixation, and outcome were recorded using the patients’ notes. The General Register Office for Scotland was used to obtain the mortality status of the patients.

There were 276 total hip replacements (THR), 123 total knee replacements (TKR), 117 hemiarthroplasty, and 114 “other” implants. The incidence of periprosthetic fractures increased significantly during the study period for all implants: THR (p<0.001), TKR (p<0.001), hemiarthroplasty (p=0.002), and other (p=0.003). The majority of fractures were fixed by open reduction and internal fixation (72%). This failed in 14% of THR, 15% of TKR, 21% of hemiarthroplasties, and 18% of “other” implants. Isolated independent predictors of failure of fixation, after multivariate regression analysis, were increasing age, deprivation, a past medical history of asthma or chronic obstructive airways disease, osteoporosis, and steroid use (p<0.05). Failure of fixation was associated with a significantly increased one year mortality rate (OR 12.5, p=0.003).

Periprosthetic fractures involving THR and TKR are becoming more prevalent. Patient demographics can be used to calculate the risk of failure of fixation, and those with an increased risk may benefit from revision of their implant, and avert the associate morbidity of failure of fixation.

Background

There is increasing interest in the use of Total Hip Replacement (THR) for reconstruction in patients who have suffered displaced intracapsular hip fractures. Patient selection is important for good outcomes but criteria have only recently been clearly defined in the form of national guidelines. This study aims to investigate patient reported outcomes and satisfaction after Total Hip Replacement (THR) undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis in order to assess the safety and effectiveness of national clinical guidelines.

We evaluated the use of a cemented Constrained Acetabular Component to treat recurrent or potential instability after hip replacement. Over a seven year period, 109 patients who had undergone 110 operations were identified from hospital records. Patients were reviewed based on clinical and radiological follow-up. Post-operative mobility and quality of life was assessed using the Oxford Hip Score (OHS) and SF-12.

From an original cohort of 109 patients, 9 patients were lost to follow up. Of the remaining 100 patients, the mean follow up was 2.9 years (SD+/−2 years). There were 4 failures, requiring 3 further revisions. The mean post-operative OHS was 33, SF-12 PCS 34 and SF12 MCS 52. 5-year survivorship was 90%. Cementing a Constrained Acetabular Component provides satisfactory mid term results in patients at high risk of hip dislocation.

A prospective study was performed to develop a clinical prediction rule that incorporated demographic and clinical factors predictive of a fracture of the scaphoid. Of 260 consecutive patients with a clinically suspected or radiologically confirmed scaphoid fracture, 223 returned for evaluation two weeks after injury and formed the basis of our analysis. Patients were evaluated within 72 hours of injury and at approximately two and six weeks after injury using clinical assessment and standard radiographs. Demographic data and the results of seven specific tests in the clinical examination were recorded.

There were 116 (52%) men and their mean age was 33 years (13 to 95; sd 17.9). In 62 patients (28%) a scaphoid fracture was confirmed. A logistic regression model identified male gender (p = 0.002), sports injury (p = 0.004), anatomical snuff box pain on ulnar deviation of the wrist within 72 hours of injury (p < 0.001), and scaphoid tubercle tenderness at two weeks (p < 0.001) as independent predictors of fracture. All patients with no pain at the anatomical snuff box on ulnar deviation of the wrist within 72 hours of injury did not have a fracture (n = 72, 32%). With four independently significant factors positive, the risk of fracture was 91%.

Our study has demonstrated that clinical prediction rules have a considerable influence on the probability of a suspected scaphoid fracture. This will help improve the use of supplementary investigations where the diagnosis remains in doubt.

Introduction: Cement pressurisation is key to achieving good cement-bone interdigitation in THR. To obtain adequate pressurisation the medullary canal must be sealed distally using a cement restrictor. The cement restrictor must remain stable in the femoral canal.

Methods: Five different cement restrictors were evaluated, namely the Exeter Cement Plug, Biostop G, Hardinge, Rex CementStop and a preinjected cement plug. The restrictor was deployed in a sawbone that had been reamed to produce a distal flare, based on radiographic measurements. Low viscosity bone cement pressurised using a cement ram connected to a 10bar air supply. An electronic pressure valve increased the pressure in the cement. Cement pressure and cement restrictor displacement were continuously measured. The pressure valve and recording of measurements was controlled by a customised computer package.

Results: The Rex CementStop withstood the greatest pressures (mean 565.8kPa). This was a significantly greater pressure than any of the other cement restrictors (p< 0.001). Pre-injected cement plugs were able to resist the next highest pressures (mean 350.4kPa). They did not displace but leaked cement and were technically difficult to deliver in the distal femur. Cement restrictors that function well above the isthmus were ineffective (Biostop mean 118.7kPa) or could not be deployed below the isthmus (Exeter). The Hardinge recorded a mean 162.3kPa.

Discussion: During pre-operative templating it is important to consider where the cement restrictor will sit in the femur. When the cement restrictor is going to be deployed beyond the femoral isthmus, an alternate method of cement restriction may need to be used. Universal sized plugs (e.g. Hardinge) function poorly in this situation. Press-fit plugs such as Biostop and Exeter are severely compromised when inserted past the femoral isthmus. Pre-injected cement plugs are variable in efficacy. The expandable Rex CementStop reliably occluded the femur, allowing the highest pressures to be generated.

There is little evidence describing the influence of body mass index on the outcome of Total Hip Replacement (THR). There are concerns that an increasing BMI may lead to increased blood loss, infection and venous thromboembolism. 800 consecutive patients undergoing primary cemented THR were followed for a minimum of 18 months. The Harris Hip Score (HHS) and SF-36 were recorded pre-operatively and at 6 and 18 months post-operatively. In addition other significant events were noted, namely death, dislocation, re-operation, superficial and deep infection and blood loss. Multiple regression analysis was performed to identify whether BMI was an independently significant predictor of the outcome of THR.

No relationship was seen between the BMI of an individual and the development of any of the complications noted. The HHS was seen to increase dramatically post-operatively in all patients. BMI did predict for a lower HHS at 6 and 18 months, and a lower physical functioning component of the SF-36 at 18 months. This effect was small when compared with the overall improvements in these scores.

Conclusion: THR provides good symptomatic relief irrespective of BMI. On the basis of this study we can find no justification for withholding THR solely on the grounds of BMI.

Aims: To evaluate the function of cement restrictors beyond the femoral isthmus.

Introduction: Pressurisation of cement is key to achieving good cement-bone interdigitation in Total Hip Replacement. During insertion of the femoral stem, pressures of up to 1000kPa may be generated. To maintain pressurisation the medullary canal must be sealed distally using a cement restrictor. As a secondary effect, cement restrictors also prevent excess injection of cement into the medullary canal. To fulfil these functions the cement restrictor must remain stable in the femoral canal.

Methods: Five different cement restrictors were evaluated, namely the Exeter Cement Plug (Stryker, UK), Biostop (De Puy, UK), Hardinge (De Puy, UK), Rex CementStop (A-One-Medical, Netherlands) and a preinjected cement plug (Surgical Simplex, Stryker, UK). The restrictor was deployed in a sawbone that had been rasped to produce a distal flare. Low viscosity bone cement (Surgical Simplex, Stryker, UK) was injected and pressurised using a custom made cement ram connected to a 10bar pressurised air supply. An electronically controlled pressure valve increased the pressure in the cement. Pressure in the cement was measured using a pressure transducer. A linear variable displacement transducer was used to measure movement of the cement restrictor. Leakage of cement around the restrictor was also recorded. Activation of the pressure valve and recording of measurements was controlled by a customised computer package.

Results: The Rex CementStop withstood the greatest pressures (mean 565.8kPa). This was a significantly greater pressure than any of the other cement restrictors (p= 0.027). Pre-injected cement plugs were able to resist the next highest pressures (mean 350.4kPa). They did not displace but leaked cement and were technically difficult to deliver in the distal femur. Cement restrictors that function well above the isthmus were ineffective (Biostop mean 118.7kPa) or could not be deployed below the isthmus (Exeter). The Hardinge cement restrictor recorded a mean 162.3kPa.

Discussion: It is important for a surgeon to consider where the cement restrictor will sit in the femur during pre-operative templating in Total Hip Replacement. When the cement restrictor is going to be deployed beyond the femoral isthmus, an alternate method of cement restriction may need to be used. Universal sized plugs (e.g. Hardinge) function poorly in this situation. Press-fit plugs such as Biostop and Exeter have been previously shown to allow the generation of high pressures in bone cement when sited above the femoral isthmus or in stove pipe femurs. However their function is severely compromised when inserted past the femoral isthmus. Pre-injected cement plugs are variable in efficacy. The expandable Rex CementStop was simple to use and reliably occluded the femur, allowing the highest pressures to be generated.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

This prospective study aimed to establish if octogenarians undergoing primary hip arthroplasty experienced a similar clinical outcome and complication rate as younger patients.

A total of 585 patients were recruited over a 4-year period. Patients aged 70–79 years and 80–89 years (octogenarians) were placed into separate groups.

Harris hip and SF-36 scores were obtained before and at 6 and 18 months following surgery. Other measurements included: blood loss; blood transfusion rate; wound infection; thromboembolism; dislocation and 90-day mortality.

Statistical analysis included a two-sample t-test and chi-squared analysis with Yates correction to compare results in each group. Analysis of covariance was used to calculate confidence limits for the effect of age group on Harris hip and SF-36 scores at 6 and 18 months after adjusting for levels recorded prior to surgery. Multiple logistic regression analysis was performed to determine any predictive factors for a noted difference in blood transfusion rates between patient cohorts.

A significantly better (P=0.019) improvement in mean Harris Hip score (SD) was seen 18-months after surgery in the younger cohort (43.4 (13.8) compared to 39.8 (10.6)). Length of hospital stay was longer (P< 0.001) in the octogenarians (12.9 (SD 7.0) days versus 10.1 (SD 4.7)) with a higher blood transfusion rate of 40% compared to 28% (P = 0.009). Lower pre-operative haemoglobin levels strongly correlated with the need for blood transfusion. No significant differences in infection, dislocation, thromboembolism or 90-day mortality rates were found.

Conclusions: Octogenarians are more likely to require blood transfusion and a longer hospital stay, with less improvement in clinical outcome at 18 months after primary hip arthroplasty.

Aim: To assess the results of total knee arthroplasty in a cohort of patients aged 80–89 years and compare them to a similar group of patients aged 70–79

Introduction: With the average age of the population steadily rising, more patients are likely to present with arthritis over 80 years of age. The benefits of Total Knee Arthroplasty (TKA) in the treatment of osteoarthritis are widely known, but there are few studies which examine the results of TKA in octogenarians.

Methods: Data was collected prospectively from 1995–2002 on 115 patients undergoing TKA aged 80–89 years and compared to 411 patients who were aged 70–79 undergoing TKA during the same period. Patients undergoing unicompartmental, revision or bilateral TKA were excluded. Patients were seen pre-operatively and scores for SF-36, American Knee Society (AKS) score and haemoglobin were taken along with demographic data. The outcome measurements used were SF-36 score, AKS score, blood loss, length of stay, mortality and post-operative complications. These were collected during the first week post-surgery and at 6 and 18 months post-surgery.

Results: Both groups showed significant increases in AKS score at 6 months, (54.17 and 54.45, both p=0.0001). We continued to see improvement of the AKS score up to 18 months (mean 85.38 and 85.12, p= 0.55) with no significant difference between the two groups. Patients over 80 had lower pre-op Haemoglobin (Hb) (mean 13.56 and 12.23, p=0.0001) but experienced the same Hb drop post-procedure. There was no difference in postoperative complications, but the length of stay (8.3 days and 13.9 days, p=0.0001) and mortality rate (0.7% and 5%, p=0.0001) were higher.

Conclusions: Our early results show that TKA can be beneficial to patients over 80 years in terms of mobility and independence, but they have a longer in-patient hospital stay and attract a slightly higher mortality risk at 90 days.

Background: Previous studies have reported mixed findings with regards to post operative complication rates and overall outcome in elderly patients undergoing total hip arthroplasty. The aim of this study was a prospective comparison of physical and functional outcome measurements following primary hip arthroplasty in patients aged 80–90 years to those aged 70–79.

Methods: Data was prospectively recorded from 1998–2002. 144 patients aged 80–90 years underwent primary hip arthroplasty compared to 441 aged 70–79. A pre-operative Harris Hip Score was obtained on all patients and a standardized follow up regimen was used for assessment at 6, 18 and 36 months post surgery. Data collection included: intraoperative blood loss; post operative transfusion rate; incidence of wound infection, DVT and pulmonary embolus; dislocation and mortality rates. Statistical analysis involved two-sample t-test and chi-squared with Yates correction.

Results: Pre-operative Harris Hip Scores were 41.6 (SD 11.2) in the younger cohort and 39.3 (SD 12.4) in the octogenarian (P = 0.04). This score had improved by 39.3 and 38.1 points respectively (P = 0.5) at 6 months; 42.3 and 37.7 at 18 months (P = 0.02); 43.4 and 39.8 at 36 months (P = 0.24).

The mortality rate at 3 months following surgery was 4% in our octogenarian group compared to 1% (P=0.02). Mean length of hospital stay was significantly (P< 0.001) longer at 12.9 (SD 7.0) days compared to 10.1 (SD 4.7). The transfusion rate in our octogenarian group was 40% compared to 28% (P = 0.009). The incidence of deep infection was 1.4% in the older group compared to 0.5% (NS). Each group had a dislocation rate of 1%. and an incidence of DVT and pulmonary embolus that was comparable.

Discussion: Total hip arthroplasty can be performed safely in octogenarians with excellent relief of pain and improved function.

Introduction: There is little published on the outcome of orthopaedic surgery performed by surgeons in training. The individual results of orthopaedic units and consultants are coming under increasing scrutiny. There may be concerns that trainee performed THR will negatively impact on these figures. This study compares the outcome of THR’s performed by consultants and supervised trainees.

Methods: Data was prospectively collected on 139 THR’s carried out by supervised specialist registrars (years 1 to 4) and 397 THR’s carried out by consultants. The Harris Hip Score (HHS) was used as the primary outcome measure and scores were taken at 7days pre-operatively, 6 and 18 months post-operatively. In addition data on co-morbidity, blood loss, transfusion requirements, re-operation, dislocation and death were recorded. Radiographs of 110 trainee and 110 consultant performed THR’s were compared at 6 months. Acetabular anteversion and abduction and femoral orientation were assessed on lateral and AP films. Cementation was judged using methods described by Hodgkinson and Barrack.

Results: Blood loss, transfusion requirement, dislocation, revision, deep infection and the HHS at 6 and 18 months showed no statistically significant difference between trainee and consultant (all p< 0.05). Component orientation and cementation quality again showed no significant difference (p< 0.05).

Discussion: This paper reveals no difference in the short term results of THR performed by consultants and supervised trainees. Our results show that quality can be maintained whilst training juniors to operate.

Introduction: There is little evidence describing the influence of Body Mass Index (BMI) on the outcome of Total Hip Replacement (THR). There are concerns that an increasing BMI may increase complication rates such as superficial and deep infection, blood loss, operation time and aseptic loosening. There is evidence that obese patients receive good symptomatic relief from THR and so it is important that the advisability of surgery is made on good evidence.

Methods: 800 patients undergoing primary Charnley total hip replacement were followed prospectively for a minimum of 18 months. The Harris Hip Score (HHS) and SF-36 were recorded pre-operatively and at 6 and 18 months post-operatively. Other significant events were noted, namely death, dislocation, re-operation, superficial and deep infection and blood loss. Stepwise multiple regression analysis was performed to identify whether BMI was an independently significant predictor of the outcome of THR.

Results: The mean age of patients was 68 years, with 61% females. At 18 months 31 patients (39 hips) had died. There were 15 re-operations, 13 dislocations and 7 deep infections.

No relationship was seen between the BMI of an individual and the development of post-operative complications. The HHS was seen to increase dramatically postoperatively in all patients (mean 43 points at 18 months). BMI did predict for a lower HHS at 6 and 18 months and a lower physical functioning score on the SF-36.

Discussion: THR produces a significant improvement in symptoms in patients, irrespective of BMI. An increasing BMI does not result in an increase in the early complication rate following THR. There is a reduction in the HHS and physical function component of SF-36 with increasing BMI, although this effect is small. On the basis of this study we do not think that THR should be withheld solely on the grounds of BMI.