Aims. The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England. Methods. This retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation. Results. Among 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001). Conclusion. The cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL. Cite this article: Bone Joint J 2022;104-B(7):811–819

Aims. 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. Methods. 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. Results. This study included 780 patients. The mean one-year FJS-12 score was 65.42 (SD 28.59). The mean one-year HOOS, JR score was 82.70 (SD 16.57). A high positive correlation between FJS-12 and HOOS, JR was found (r = 0.74; p<0.001), making the HOOS, JR a valid external anchor. The threshold score of the FJS-12 that maximized the sensitivity and specificity for detecting a PASS was 66.68 (area under the curve = 0.8). The cut-off score value computed with the 75th percentile approach was 92.20. Conclusion. The PASS threshold for the FJS-12 at one year following primary THA was 66.68 and 92.20 using the ROC curve and 75th percentile approaches, respectively. These values can be used to achieve consensus about meaningful postoperative improvement to maximize the utility of the FJS-12 to evaluate and counsel patients undergoing THA. Cite this article: Bone Jt Open 2022;3(4):307–313

Aims. The aim of this study was to report the long-term follow-up of cemented short Exeter femoral components when used in primary total hip arthroplasty (THA). Methods. We included all primary 394 THAs with a cemented short Exeter femoral component (≤ 125 mm) used in our tertiary referral centre between October 1993 and December 2021. A total of 83 patients (21%) were male. The median age of the patients at the time of surgery was 42 years (interquartile range (IQR) 30 to 55). The main indication for THA was a childhood hip disease (202; 51%). The median follow-up was 6.7 years (IQR 3.1 to 11.0). Kaplan-Meier survival analyses were performed to determine the rates of survival with femoral revision for any indication, for septic loosening, for fracture of the femoral component and for aseptic loosening as endpoints. The indications for revision were evaluated. Fractures of the femoral component were described in detail. Results. The 20-year rate of survival was 85.4% (95% confidence interval (CI) 73.9 to 92.0) with revision for any indication, 96.2% (95% CI 90.5 to 98.5) with revision for septic loosening and 92.7% (95% CI 78.5 to 97.6) with revision for fracture of the femoral component. No femoral components were revised for aseptic loosening. There were 21 revisions of the femoral component; most (seven) as part of a two-stage management of infection. Fracture of the femoral component occurred in four THAs (1.0%) at 6.6, 11.6, 16.5, and 18.2 years of follow-up, respectively. Three of these were transverse fractures and occurred at the level of the lesser trochanter. In one THA, there was a fracture of the neck of the component. Conclusion. THAs using cemented short Exeter femoral components showed acceptable rates of survival of the femoral component at long-term follow-up, in this young cohort of patients. Although fracture is a rare complication of these components, surgeons should be aware of their incidence and possible risk factors. Cite this article: Bone Joint J 2024;106-B(3 Supple A):137–142

Aims. The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR. Methods. We analyzed 328,737 primary THAs using the Exeter V40 stem, comprising 34.3% of the 958,869 from the start of the NJR to December 2018. Our exposure was the stem, and the outcome was all-cause construct revision. We stratified analyses into four groups: constructs using the 44/00/125 stem, those using the 44/0/150 stem, those including a 35.5/125 stem, and constructs using any other Exeter V40 stem. Results. In all 328,737 THAs using an Exeter V40 stem, the revision estimate was 2.8% (95% confidence interval (CI) 2.7 to 2.8). The 44/00/125 stem was implanted in 2,158 primary THAs, and the ten-year revision estimate was 4.9% (95% CI 3.6 to 6.8). Controlling for age, sex, year of operation, indication, and American Society of Anesthesiologists grade demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (hazard ratio 1.8 (95% CI 1.4 to 2.3)). Conclusion. Although the revision estimate is within the National Institute for Health and Care Excellence ten-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the range. Adjusted analyses will not take into account ‘confounding by indication’, e.g. patients with complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured but be aware of the observed increased revision estimate, and only use this stem when other implants are not suitable. Cite this article: Bone Joint J 2023;105-B(5):504–510

Aims. Several short- and mid-term studies have shown minimal liner wear of highly cross-linked polyethylene (HXLPE) in total hip arthroplasty (THA), but the safety of using thinner HXLPE liners to maximize femoral head size remains uncertain. The objective of this study was to analyze clinical survival and radiological wear rates of patients with HXLPE liners, a 36 mm femoral head, and a small acetabular component with a minimum of ten years’ follow-up. Methods. We retrospectively identified 55 patients who underwent primary THA performed at a single centre, using HXLPE liners with 36 mm cobalt-chrome heads in acetabular components with an outer diameter of 52 mm or smaller. Patient demographic details, implant details, death, and all-cause revisions were recorded. Cox regression and Kaplan-Meier survival was used to determine all-cause and liner-specific revision. Of these 55 patients, 22 had a minimum radiological follow-up of seven years and were assessed radiologically for linear and volumetric wear. Results. Overall survival rate for all-cause revision was 94.5% (95% confidence interval (CI) 81.7% to 97.2%) at a mean follow-up of 12.8 years (10.9 to 18.7). Three patients were revised, none for liner wear, fracture, or dissociation. A total of 22 patients were included in the radiological analysis (mean follow-up 9.9 years (7.5 to 13.7)). Mean linear liner wear was 0.085 mm (95% CI -0.086 to 0.257) and the volumetric wear rate was 11.097 mm. 3. /year (95% CI -6.5 to 28.7). Conclusion. Using HXLPE liners with 36 mm heads in 52 mm acetabular components or smaller is safe, with excellent survival and low rates of linear and volumetric wear at medium-term follow-up. Patients did not require revision surgery for liner complications such as fracture, dissociation, or wear. Our results suggest that the advantages of using larger heads outweigh the potential risks of using thin HXLPE liners. Cite this article: Bone Joint J 2023;105-B(1):29–34

Aims

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component.

Aims

The aim of our study was to investigate the effect of asymmetric crosslinked polyethylene liner use on the risk of revision of cementless and hybrid total hip arthroplasties (THAs).

Introduction

Total hip arthroplasty (THA) is the only successful treatment for patients in whom the hip joint is destroyed by inflammatory arthritis. Due to the effects of both the disease and its treatment elevated rates of complications and of aseptic loosening have been described. Whether with modern uncemented hip prostheses the results can be improved is not fully known. Therefore, we decided to carry out a prospective study.

Material and methods

At the introduction of a new press-fit acetabular component a prospective study on the results of uncemented THA was started. From 1995 to 1999 85 primary THAs were carried out in 72 patients (57 women, 15 men) suffering from inflammatory arthritis. Diagnosis: RA 76, adult-onset Still 4, JIA 3, miscellaneous 2. Mean age at operation was 60 years (SD 15. 9). Clinically, the Harris Hip Score was used for evaluation. Radiographically, the Larsen classification was used and at follow-up radiolucencies and signs of migration were registered.

The implants used in this study were the EPF-PLUS® acetabular component and the SL-PLUS® femoral component (PLUS Endoprothetik AG, Rotkreuz-CH). The EPF-PLUS® acetabular component is a novel modular press-fit cup. Its shell has a triple radius profile on cross-section, thereby creating a gradual lowering of the polar part of the cup. This produces a small gap of about 2 mm. between the acetabulum and the pole of the cup. Therefore, forces are mainly transmitted to the peripheral part of the acetabulum, leading to an enhanced primary stability. Originally, the shell had a gritblasted surface for osseointegration. Since 1996, the outer surface of the cup has been coated with a ground layer of pure titanium and a superficial layer of a crystalline hydroxyapatite (Ti-HA). The gritblasted version was used in 14 hips (1995–1996), the Ti-HA coated version in 71 hips. In 68 hips the cup was implanted by press-fit fixation, in 17 screws were added.

Results

Larsen classification was as follows: 0-1: 6; 3: 17; 4: 60; 5: 2. At follow-up, 5 patients (6 THAs) were deceased. Deep infection required revision in one hip. Another revision was carried out for recurrent dislocations. One grit-blasted cup developed late subsidence and was revised almost 4 years postoperatively. One Ti-HA coated cup failed early due to severe acetabular bone loss. Finally, one femoral component developed a varus tilt and became symptomatic 2 years after implantation, requiring revision. In all 62 patients with 74 THAs in follow-up cup and stem are functioning well, both clinically and radiographically. Harris Hip Score increased from 36. 6 (SD 17. 7) to 87. 9 (SD 11. 8).

Discussion

The medium-term results of the EPF®-PLUS cup show that its primary stability is good and that, as the polar gap rapidly disappears, osseointegration is secure. Only severe acetabular deficiency appears to be a contra-indication for this implant. Also, the SL-PLUS® stem performs well in inflammatory arthritis.

Aims. Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods. We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m. 2. (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results. The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion. Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis. Cite this article: Bone Joint J 2023;105-B(7):768–774

Aims. Periprosthetic femoral fracture (PPF) is a major complication following total hip arthroplasty (THA). Uncemented femoral components are widely preferred in primary THA, but are associated with higher PPF risk than cemented components. Collared components have reduced PPF rates following uncemented primary THA compared to collarless components, while maintaining similar prosthetic designs. The purpose of this study was to analyze PPF rate between collarless and collared component designs in a consecutive cohort of posterior approach THAs performed by two high-volume surgeons. Methods. This retrospective series included 1,888 uncemented primary THAs using the posterior approach performed by two surgeons (PKS, JMV) from January 2016 to December 2022. Both surgeons switched from collarless to collared components in mid-2020, which was the only change in surgical practice. Data related to component design, PPF rate, and requirement for revision surgery were collected. A total of 1,123 patients (59.5%) received a collarless femoral component and 765 (40.5%) received a collared component. PPFs were identified using medical records and radiological imaging. Fracture rates between collared and collarless components were analyzed. Power analysis confirmed 80% power of the sample to detect a significant difference in PPF rates, and a Fisher’s exact test was performed to determine an association between collared and collarless component use on PPF rates. Results. Overall, 17 PPFs occurred (0.9%). There were 16 fractures out of 1,123 collarless femoral components (1.42%) and one fracture out of 765 collared components (0.13%; p = 0.002). The majority of fractures (n = 14; 82.4%) occurred within 90 days of primary THA. There were ten reoperations for PPF with collarless components (0.89%) and one reoperation with a collared component (0.13%; p = 0.034). Conclusion. Collared femoral components were associated with significant decreases in PPF rate and reoperation rate for PPF compared to collarless components in uncemented primary THA. Future studies should investigate whether new-generation collared components reduce PPF rates with longer-term follow-up. Cite this article: Bone Joint J 2024;106-B(3 Supple A):115–120

Aims. Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA. Methods. Our total joint registry identified patients with breast cancer history undergoing primary THA (n = 423) and TKA (n = 540). Patients were matched 1:1 based upon age, sex, BMI, procedure (hip or knee), and surgical year to non-breast cancer controls. Mortality, implant survival, and complications were assessed via Kaplan-Meier methods. Clinical outcomes were evaluated via Harris Hip Scores (HHSs) or Knee Society Scores (KSSs). Mean follow-up was six years (2 to 15). Results. Breast cancer patient survival at five years was 92% (95% confidence interval (CI) 89% to 95%) after THA and 94% (95% CI 92% to 97%) after TKA. Breast and non-breast cancer patients had similar five-year implant survival free of any reoperation or revision after THA (p ≥ 0.412) and TKA (p ≥ 0.271). Breast cancer patients demonstrated significantly lower survival free of any complications after THA (91% vs 96%, respectively; hazard ratio = 2 (95% CI 1.1 to 3.4); p = 0.017). Specifically, the rate of intraoperative fracture was 2.4% vs 1.4%, and venous thromboembolism (VTE) was 1.4% and 0.5% for breast cancer and controls, respectively, after THA. No significant difference was noted in any complications after TKA (p ≥ 0.323). Both breast and non-breast cancer patients experienced similar improvements in HHSs (p = 0.514) and KSSs (p = 0.132). Conclusion. Breast cancer survivors did not have a significantly increased risk of mortality or reoperation after primary THA and TKA. However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE. Cite this article: Bone Joint J 2024;106-B(4):365–371

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF. Cite this article: Bone Joint J 2024;106-B(1):11–15

Aims. There is inconsistent evidence on whether prior spinal fusion surgery adversely impacts outcomes following total hip arthroplasty (THA). We conducted a systematic review and meta-analysis to assess the association between pre-existing spinal fusion surgery and the rate of complications following primary THA. Methods. We searched MEDLINE, Embase, Web of Science, and Cochrane Library up to October 2019 for randomized controlled trials (RCTs) and observational studies comparing outcomes of dislocation, revision, or reasons for revision in patients following primary THA with or without pre-existing spinal fusion surgery. Furthermore, we compared short (two or less levels) or long (three or more levels) spinal fusions to no fusion. Summary measures of association were relative risks (RRs) (with 95% confidence intervals (CIs)). Results. We identified ten articles corresponding to nine unique observational studies comprising of 1,992,366 primary THAs. No RCTs were identified. There were 32,945 cases of spinal fusion and 1,752,362 non-cases. Comparing prior spinal fusion versus no spinal fusion in primary THA, RRs (95% CI) for dislocation was 2.23 (1.81 to 2.74; seven studies), revision 2.14 (1.63 to 2.83; five studies), periprosthetic joint infection 1.71 (1.53 to 1.92; four studies), periprosthetic fracture 1.52 (1.28 to 1.81; three studies), aseptic loosening 1.76 (1.54 to 2.01; three studies), and any complications 2.82 (1.37 to 5.80; three studies) were identified. Both short and long spinal fusions, when compared with no fusion, were associated dislocation, revision, or reasons for revision. Conclusions. Patients with prior spinal fusion are at risk of adverse events following primary THA. Measures that reduce the risk of these complications should be considered in this high-risk population when undergoing primary THA. These patients should also be counselled appropriately around their risks of undergoing THA. Cite this article: Bone Joint J 2020;102-B(6):664–670

Aims. Although there is increasing legalization of the use of cannabis in the USA, few well-powered studies have evaluated the association between cannabis use disorder and outcomes following primary total hip arthroplasty (THA). Thus, the aim of this study was to determine whether patients who use cannabis and undergo primary THA have higher rates of in-hospital length of stay (LOS), medical complications, implant-related complications, and costs. Methods. Using an administrative database, patients with cannabis use disorder undergoing primary THA were matched to a control group in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 23,030 patients (3,842 in the study group matched with 19,188 in the control group). The variables which were studied included LOS, 90-day medical complications, two-year implant-related complications, and 90-day costs of care. Mann-Whitney U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. Results. We found that patients in the study group had a significantly longer mean LOS compared with the controls (four days vs three days; p < 0.0001).The study group also had a significantly higher incidence and odds of developing medical (23.0 vs 9.8%, OR 1.6; p < 0.0001) and implant-related complications (16 vs 7.4%, OR 1.6; p < 0.0001) and incurred significantly higher mean 90-day costs ($16,938.00 vs $16,023.00; p < 0.0001). Conclusion. With the increasing rates of cannabis use, these findings allow orthopaedic surgeons and other healthcare professionals to counsel patients with cannabis use disorder about the possible outcomes following their THA, with increased hospital stays, complications, and costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):111–115

Arthrofibrosis is a relatively frequent complication after total knee arthroplasty. Although stiffness after total hip arthroplasty (THA), because of formation of heterotopic ossification or other causes, is not uncommon, to the authors’ best knowledge, arthrofibrosis after THA has not been described. The aim of this study is to describe the arthrofibrosis of the hip after primary total hip arthroplasty using an established clinical and histological classification of arthrofibrosis. We retrospectively examined all patients who were histologically confirmed to have arthrofibrosis after primary THA during revision surgery by examination of tissue samples in our clinic. Arthrofibrosis was diagnosed according to the histopathological SLIM-consensus classification, which defines seven different SLIM types of the periimplant synovial membrane. The SLIM type V determines the diagnosis of endoprosthesis-associated arthrofibrosis. The study population consists of 66 patients who were revised due to arthrofibrosis after primary THA. All patients had a limitation in range of motion prior to revision with a mean flexion of 90° (range from 40 to 125), mean internal rotation of 10° (range from 0 to 40) and mean external rotation of 20° (range from 0 to 50). All patients had histological SLIM type V arthrofibrosis, corresponding to endoprosthesis-associated arthrofibrosis. Histological examination revealed that seven patients (10.6%) had particle-induced and 59 patients (89.4%) had non-particle-induced arthrofibrosis. This is the first decription of endoprosthetic-associated arthrofibrosis after primary THA on the basis of a well-established histological classification. Our study results could enable new therapeutic and diagnostic opportunities in patients with such an arthrofibrosis. Surgeons should keep arthrofibrosis as a possible cause for stiffness and pain after primary total hip arthroplasty in mind. Level of evidence Diagnostic study, Level of Evidence IV. Thorsten Gehrke and Lara Althaus contributed equally to the writing of this manuscript

Aims. The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation. Methods. Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded. Results. Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report “much better” joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all). Conclusion. The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty. Cite this article: Bone Joint J 2023;105-B(5):526–533

Aims. In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Methods. Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups. Results. From six months postoperatively onwards, patients aged ≥ 75 years undergoing primary THA with primary diagnosis of OA have a lower risk of all-cause revision with collared cementless components than with a polished tapered cemented component (HR 0.78 (95% confidence interval 0.64 to 0.96); p = 0.018). There is no difference in revision rate prior to six months. Conclusion. Patients aged ≥ 75 years with a primary diagnosis of OA have a significantly lower rate of revision with the most common collared cementless femoral component, compared with the most common polished tapered cemented components from six months postoperatively onwards. The lower revision rate is largely due to a reduction in revisions for fracture and infection. Cite this article: Bone Joint J 2024;106-B(3 Supple A):121–129

In primary total hip arthroplasty (THA) for patients with Crowe II or higher classes developmental dysplasia of the hip (DDH) or rapidly destructive coxopathy (RDC), the placement of the cup can be challenging due to superior and lateral acetabular bone defects. Traditionally, bone grafts from resected femoral heads were used to fill these defects, but bulk graft poses a risk of collapse, especially in DDH with hypoplastic femoral heads or in RDC where good quality bone is scarce. Recently, porous metal augments have shown promising outcomes in revision surgeries, yet reports on their efficacy in primary THA are limited. This study retrospectively evaluated 27 patients (30 hips) who underwent primary THA using cementless cups and porous titanium acetabular augments for DDH or RDC, with follow-up periods ranging from 2 to 10 years (average 4.1 years). The cohort included 22 females (24 hips) and 5 males (6 hips), with an average age of 67 years at the time of surgery. The findings at the final follow-up showed no radiographic evidence of loosening or radiolucency around the cups and augments, indicating successful biological fixation in all cases. Clinically, there was a significant improvement in the WOMAC score from an average of 39.1±14.7 preoperatively to 5.1±6.4 postoperatively. These results suggest that the use of cementless cups and porous titanium acetabular augments in primary THA for DDH and RDC can lead to high levels of clinical improvement and reliable biological fixation, indicating their potential as a viable solution for managing challenging acetabular defects in these conditions

Aims. Routinely collected patient-reported outcome measures (PROMs) have been useful to quantify and quality-assess provision of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in the UK for the past decade. This study aimed to explore whether the outcome following primary THA and TKA had improved over the past seven years. Methods. Secondary data analysis of 277,430 primary THAs and 308,007 primary TKAs from the NHS PROMs programme was undertaken. Outcome measures were: postoperative Oxford Hip/Knee Score (OHS/OKS); proportion of patients achieving a clinically important improvement in joint function (responders); quality of life; patient satisfaction; perceived success; and complication rates. Outcome measures were compared based on year of surgery using multiple linear and logistic regression models. Results. For primary THA, multiple linear regression modelling found that more recent year of surgery was associated with higher postoperative OHS (unstandardized coefficient (B) 0.15 points (95% confidence interval (CI) 0.14 to 0.17); p < 0.001) and higher EuroQol five-dimension index (EQ-5D) utility (B 0.002 (95% CI 0.001 to 0.002); p < 0.001). The odds of being a responder (odds ratio (OR) 1.02 (95% CI 1.02 to 1.03); p < 0.001) and patient satisfaction (OR 1.02 (95% CI 1.01 to 1.03); p < 0.001) increased with year of surgery, while the odds of any complication reduced (OR 0.97 (95% CI 0.97 to 0.98); p < 0.001). No trend was found for perceived success (p = 0.555). For primary TKA, multiple linear regression modelling found that more recent year of surgery was associated with higher postoperative OKS (B 0.21 points (95% CI 0.19 to 0.22); p < 0.001) and higher EQ-5D utility (B 0.002 (95% CI 0.002 to 0.003); p < 0.001). The odds of being a responder (OR 1.04 (95% CI 1.03 to 1.04); p < 0.001), perceived success (OR 1.02 (95% CI 1.01 to 1.02); p < 0.001), and patient satisfaction (OR 1.02 (95% CI 1.01 to 1.02); p < 0.001) all increased with year of surgery, while the odds of any complication reduced (OR 0.97 (95% CI 0.97 to 0.97); p < 0.001). Conclusion. Nearly all patient-reported outcomes following primary THA/TKA improved by a small amount over the past seven years. Due to the high proportion of patients achieving good outcomes, PROMs following THA and TKA may need to focus on better discrimination of patients achieving high scores to be able to continue to measure improvement in outcomes. Cite this article: Bone Joint J 2022;104-B(6):687–695

Literature data show varying rates of aseptic loosening of standard hemispherical cups after primary total hip arthroplasty (THA) in patients with Crowe IV developmental dysplasia of the hip (DDH). In order to improve the results regarding the frequency of aseptic loosening of the acetabular component, we decided to use custom-made acetabular implants (CMAI) in this category of patients. The aim of our study was to report outcomes after primary THA using CMAI in patients with Crowe IV DDH. We retrospectively analyzed the results of primary THA using the CMAI in 58 hips. The mean follow-up period was 5.2 years (range 4.2 – 6.3). Patients demonstrated improved functional outcomes according to the Oxford Hip Score: preoperatively 16.9 and postoperatively 38.5 (P < 0.05). Revisions were performed in 2 cases due to dislocations, in 1 case due to nonunion of the greater trochanter and in 1 case due to chronic pain syndrome caused by contact of the CMAI flange with the iliopsoas muscle. In a patient with chronic pain syndrome, during the revision, the pubic flange of the CMAI, which was in contact with the iliopsoas muscle, was removed. There were no radiological signs of loosening of the CMAI. The use of CMAI shows good results in patients with DDH. Extended capability for supplementary screw fixation is an excellent feature of such implants, allowing them to obtain reliable primary fixation. Further observation is required to assess CMAI in the long-term follow-up

Abstract. Background. Although tantalum is a well recognised implant material used for revision arthroplasty, little is known regarding the use of the same in primary total hip arthroplasty. Methods. A literature search was performed to find all relevant clinical studies until March 2020, which then underwent a further selection criteria. The inclusion criteria was set as follows: Reporting on human patients undergoing primary total hip arthroplasty; Direct comparison between tantalum acetabular cups with conventional acetabular cups. for use in primary total hip arthroplasty; Radiological evaluation (cup migration, osteointegration); Clinical (functional scores, need for subsequent revision, patient-reported outcomes; Post-operative complications; Reporting findings in the English Language. After a thorough search a total of six studies were included in the review. The primary outcome. measures were clinical outcomes, implant migration, change in bone mineral density and rate of revision and infection. Results. Tantalum was found superior to titanium with regards to fewer radiolucencies, survivorship, osteointegration, decreased osteolysis and mechanical loosening. No significant difference in radioisometric analysis, bone mineral density or Harris Hip Score was found. Revision and infection rates were found to be significantly lower in tantalum group at 10 years from pooled data of national joint registry. Conclusion. The use of tantalum can be reserved for cases of high risk of failure or mechanical loosening, where failure of a contralateral joint occurred as it carries lower risk of failure and infection. Further studies with longer follow-up would be useful in drawing further conclusions

Aim. Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. Method. We obtained data on patients undergoing primary THA in Sweden (n = 45,723 patients, 49,946 THAs), 2012–2014. Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks antibiotic consumption were reviewed to verify PJI diagnosis (n = 2240, 2569 THAs). Results. The cumulative incidence of PJI following the PRISS project was 1.2% [95% CI 1.1–1.3] as compared to 0.9% [95% CI 0.8–1.0] before. Cox regression models for the PJI incidence post PRISS indicates there were no statistical significance difference versus pre PRISS (HR 1.1 [95% CI 0.9–1.3]. There were similar time to PJI diagnosis after the PRISS project 24 vs 23 days (p=0.5). Conclusions. Despite the comprehensive nationwide PRISS project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher ASA class, and more fractures as indications, explain the PJI increase among primary THA patients

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

Aims. Adverse spinal motion or balance (spine mobility) and adverse pelvic mobility, in combination, are often referred to as adverse spinopelvic mobility (SPM). A stiff lumbar spine, large posterior standing pelvic tilt, and severe sagittal spinal deformity have been identified as risk factors for increased hip instability. Adverse SPM can create functional malposition of the acetabular components and hence is an instability risk. Adverse pelvic mobility is often, but not always, associated with abnormal spinal motion parameters. Dislocation rates for dual-mobility articulations (DMAs) have been reported to be between 0% and 1.1%. The aim of this study was to determine the early survivorship from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of patients with adverse SPM who received a DMA. Methods. A multicentre study was performed using data from 227 patients undergoing primary total hip arthroplasty (THA), enrolled consecutively. All the patients who had one or more adverse spine or pelvic mobility parameter had a DMA inserted at the time of their surgery. The mean age was 76 years (22 to 93) and 63% were female (n = 145). At a mean of 14 months (5 to 31) postoperatively, the AOANJRR was analyzed for follow-up information. Reasons for revision and types of revision were identified. Results. The AOANJRR reported two revisions: one due to infection, and the second due to femoral component loosening. No revisions for dislocation were reported. One patient died with the prosthesis in situ. Kaplan-Meier survival rate was 99.1% (95% confidence interval 98.3 to 100) at 14 months (number at risk 104). Conclusion. In our cohort of patients undergoing primary THA with one or more factor associated with adverse SPM, DM bearings conferred stability at two years’ follow-up. Cite this article: Bone Joint J 2022;104-B(7):820–825

Aims. The aim of this study was to analyze the effect of a lateral rim mesh on the survival of primary total hip arthroplasty (THA) in young patients, aged 50 years or younger. Patients and Methods. We compared a study group of 235 patients (257 hips) who received a primary THA with the use of impaction bone grafting (IBG) with an additional lateral rim mesh with a group of 306 patients (343 hips) who received IBG in the absence of a lateral rim mesh during the same period from 1988 to 2015. In the mesh group, there were 74 male and 183 female patients, with a mean age of 35 years (13 to 50). In the no-mesh group, there were 173 male and 170 female patients, with a mean age of 38 years (12.6 to 50). Cox regression analyses were performed to study the effect of a lateral rim mesh on acetabular component survival. Kaplan–Meier analyses with 95% confidence intervals (CIs) were performed to estimate the survival of the acetabular implant. Results. The hazard ratio for the use of lateral rim mesh, adjusted for potential confounders, for acetabular revision for any reason was 0.50 (95% CI 0.13 to 1.93; p = 0.31) and for acetabular revision for aseptic loosening was 0.29 (95% CI 0.020 to 4.04; p = 0.35). The Kaplan–Meier analysis showed a ten-year survival for aseptic loosening of the acetabular of 98% (95% CI 95 to 100, n = 65 at risk) in the mesh group and 94% (89 to 98, n = 76 at risk) in the no-mesh group. The 15-year survival for aseptic acetabular loosening was 90% (81 to 100, n = 35 at risk) in the mesh group and 85% (77 to 94, n = 45 at risk) in the no-mesh group (p = 0.23). Conclusion. This study shows that the use of a lateral rim mesh in primary THA in young patients is not associated with a higher risk of revision of the acetabular component. Therefore, we consider a lateral rim mesh combined with IBG to be effective in reconstructing segmental acetabular defects in primary THA

Aims. As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. Methods. A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. Results. On average, the younger cohort (YC, n = 10,251) was a mean 61.60 years old (SD 10.71), while the older cohort (OC, n = 609) was 84.25 years old (SD 3.02) (p < 0.001). The OC had greater surgical risk based on their higher mean American Society of Anesthesiologists (ASA) scores (2.74 (SD 0.63) vs 2.30 (SD 0.63); p < 0.001) and Charlson Comorbidity Index (CCI) scores (6.26 (SD 1.71) vs 3.87 (SD 1.98); p < 0.001). While the OC stayed in the hospital longer than the YC (mean 3.5 vs 2.5 days; p < 0.001), there were no differences in 90-day emergency visits (p = 0.083), myocardial infarctions (p = 0.993), periprosthetic joint infections (p = 0.214), dislocations (p = 0.993), or aseptic failure (p = 0.993). The YC was more likely to be readmitted within 90 days (3.88% vs 2.18%, Β = 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. Conclusion. Although patients ≥ 80 years old have a greater number of comorbidities than younger patients, they had equivalent perioperative complication rates and PRO scores. This study demonstrates the safety and success of elective THA in octogenarians. Cite this article: Bone Jt Open 2021;2(7):535–539

Detection of clinical situations are the most difficult for primary THA and factors which determine the complexity. Results of 2368 primary THA performed by one surgeon in 1923 patients with various hip pathologies from 2004 to 2016 were analyzed. The time of the surgery, the bloodloss, the features of the surgical technique, the implants used, and the incidence of complications and revisions were assessed and X-ray analysis was performed. Difficult cases of primary hip arthroplasty include severe dysplasia (types B2, C1, and C2 according to the Hartofilakidis classification), post-traumatic segmental acetabular defects and pelvic discontinuity, protrusio acetabuli, iatrogenic bone ankylosis and consequences of proximal femur fractures with significant shortening of the limb. X-ray signs of difficulty included an interruption of the Shenton line of 2 cm or more (except for acute fractures of proximal femur), the femoral neck-shaft angle less than 100°, and the horizontal distance from Kohler line to center of rotation less than 20% of the diameter of the femoral head. An additional burdening factor is the previous surgical interventions on the hip joint. The ten-year survival rate for standard cases was 94.9%, and for complex cases − 92.3%. The odds ratio development of complications in complex cases compared to standard cases is OR = 8.402 (95% CI from 4.614 to 15.300). In standard cases mean HHS increased from 42.9 points before surgery to 95.3 after surgery. In complex cases mean HHS before surgery was 38.9 and after surgery improved to 81.6 points, p <0.001. The complexity of the operation cannot be determined on the basis of only the etiological factor, it is necessary to take into account the severity of anatomical changes

Aims. Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. Methods. We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA. Results. Robotic-assisted THA resulted in a lower proportion (1.5%) of implant waste compared to navigation-guided THA (2.0%) and manual THA (1.9%) (all p < 0.001). Both navigated and manual THA were more likely to waste acetabular shells (odds ratio (OR) 4.5 vs 3.1) and polyethylene liners (OR 2.2 vs 2.0) compared to robotic-assisted THA after adjusting for demographic and perioperative factors, such as surgeon experience (p < 0.001). While implant waste decreased with increasing experience for procedures performed manually (p < 0.001) or with navigation (p < 0.001), waste rates for robotic-assisted THA did not differ based on surgical experience. Conclusion. Robotic-assisted THAs wasted a smaller proportion of acetabular shells and polyethylene liners than navigation-guided and manual THAs. Individual implant waste rates vary depending on the type of technology used intraoperatively. Future studies on implant waste during THA should examine reasons for non-implantation in order to better understand and develop methods for cost-saving. Cite this article: Bone Jt Open 2024;5(8):715–720

Aims. Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods. TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results. Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion. This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542

Aims. The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). Methods. Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. Results. A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). Conclusion. Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable. Cite this article: Bone Joint J 2023;105-B(2):124–134

Aims. Femoral bone preparation using compaction technique has been shown to preserve bone and improve implant fixation in animal models. No long-term clinical outcomes are available. There are no significant long-term differences between compaction and broaching techniques for primary total hip arthroplasty (THA) in terms of migration, clinical, and radiological outcomes. Methods. A total of 28 patients received one-stage bilateral primary THA with cementless femoral stems (56 hips). They were randomized to compaction on one femur and broaching on the contralateral femur. Overall, 13 patients were lost to the ten-year follow-up leaving 30 hips to be evaluated in terms of stem migration (using radiostereometry), radiological changes, Harris Hip Score, Oxford Hip Score, and complications. Results. Over a mean follow-up period of 10.6 years, the mean stem subsidence was similar between groups, with a mean of -1.20 mm (95% confidence interval (CI) -2.28 to -0.12) in the broaching group and a mean of -0.73 mm (95% CI -1.65 to 0.20) in the compaction group (p = 0.07). The long-term migration patterns of all stems were similar. The clinical and radiological outcomes were similar between groups. There were two intraoperative fractures in the compaction group that were fixed with cable wire and healed without complications. No stems were revised. Conclusion. Similar stem subsidence and radiological and clinical outcomes were identified after the use of compaction and broaching techniques of the femur at long-term follow-up. Only the compaction group had intraoperative periprosthetic femur fractures, but there were no long-term consequences of these. Cite this article: Bone Jt Open 2021;2(12):1035–1042

Primary total hip replacement (THR) is a successful and common operation which orthopaedic trainees must demonstrate competence in prior to completion of training. This study aimed to determine the impact of operating surgeon grade and level of supervision on the incidence of 1-year patient mortality and all-cause revision following elective primary THR in a large UK training centre. National Joint Registry (NJR) data for all elective primary THR performed in a single University Teaching Hospital from 2005–2020 were used, with analysis performed on the 15-year dataset divided into 5-year temporal periods (B1 2005–2010, B2 2010–2015, B3 2015–2020). Outcome measures were mortality and revision surgery at one year, in relation to lead surgeon grade, and level of supervision for trainee-led operations. 9999 eligible primary THR were undertaken, of which 5526 (55.3%) were consultant led (CL), and 4473 (44.7%) trainees led (TL). Of TL, 2404 (53.7%) were non-consultant supervised (TU), and 2069 (46.3%) consultant supervised (TS). The incidence of 1-year patient mortality was 2.05% (n=205), and all-cause revision was 1.11% (n=111). There was no difference in 1-year mortality between TL (n=82, 1.8%) and CL (n=123, 2.2%) operations (p=0.20, OR 0.78, CI 0.55–1.10). The incidence of 1-year revision was not different for TL (n=56, 1.3%) and CL (n=55, 1.0%) operations (p=0.15, OR 1.37, CI 0.89–2.09). Overall, there was no temporal change for either outcome measure between TL or CL operations. A significant increase in revision within 1-year was observed in B3 between TU (n=17, 2.7%) compared to CL (n=17, 1.0%) operations (p=0.005, OR 2.81, CI 1.35–5.87). We found no difference in 1-year mortality or 1-year all-cause revision rate between trainee-led primary THR and consultant-led operations over the entire fifteen-year period. However, unsupervised trainee led THR in the most recent 5-year block (2015–2020) has a significantly increased risk of early revision, mainly due to instability and prosthetic joint infection. This suggests that modern surgical training is having a detrimental effect on THR patient outcomes. More research is needed to understand the reasons if this trend is to be reversed

Total hip arthroplasty (THA) is one of the most successful and effective treatments for advanced hip osteoarthritis (OA). Over the last 5 years, Canada has seen a 17.8% increase in the number of hip replacements performed annually, and that number is expected to grow along with the aging Canadian population. However, the rise in THA surgery is associated with an increased number of patients at risk for the development of an infection involving the joint prosthesis and adjacent deep tissue – periprosthetic joint infections (PJI). Despite improved hygiene protocols and novel surgical strategies, PJI remains a serious complication. No previous population-based studies has investigated PJI risk factors using a time-to-event approach and none have focused exclusively on patients undergoing THA for primary hip OA. The purpose of this study is to determine risk factors for PJI after primary THA for OA using a large population-based database collected over 15 years. Our secondary objective is to determine the incidence of PJI, the time to PJI following primary THA, and if PJI rates have changed in the past 15 years. We performed a population-based cohort study using linked administrative databases in Ontario, Canada in accordance with RECORD and STROBE guidelines. All primary total hip replacements performed for osteoarthritis in patients aged 55 or older between January 1st 2002 – December 31st 2016 in Ontario, Canada were identified. Periprosthetic joint infection as the cause for revision surgery was identified with the International Classification of Diseases, 10th Edition (ICD-10), Clinical Modification diagnosis code T84.53 in any component of the healthcare data set. Data were obtained from the Institute for Clinical Evaluative Sciences (ICES). Demographic data and outcomes are summarized using descriptive statistics. We used a Cox proportional hazards model to analyze the effect of surgical factors and patient factors on the risk of developing PJI. Surgical factors include the approach, use of bone graft, use of cement, and the year of surgery. Patient factors include sex, age at surgery, income quintile and rurality (community vs. urban). We compared the 1,2,5 and 10 year PJI rates for patients undergoing THA each year of our cohort with the Cochran-Armitage test. Less than 0.1% of data were missing from all fields except for rurality which was lacking 0.3% of data. A total of 100,674 patients aged 55 or older received a primary total hip arthroplasty for osteoarthritis from 2002–2016. We identified 1034 cases of revision surgery for prosthetic joint infection for an overall PJI rate of 1.03%. When accounting for patients censored at final follow-up, the cumulative incidence for PJI is 1.44%. Our Cox proportional hazards model revealed that male sex, Type II diabetes mellitus, discharge to convalescent care, and having both hips replaced during one's lifetime were associated with increased risk of developing PJI following primary THA. Importantly, the time adjusted risk for PJI was equal for patients operated within the past 5 years, 6–10 years ago, or 11–15 years ago. The surgical approach, use of bone grafting or cement were not associated with increased risk of infection. PJI rates have not changed significantly over the past 15 years. One, two, five and ten-year PJI rates were similar for patients undergoing THA in all qualifying years. Analysis of a population-based cohort of 100,674 patients has shown that the risk of developing PJI following primary THA has not changed over 15 years. The surgical approach, use of bone grafting or cement were not associated with increased risk of infection. Male sex, Type II diabetes Mellitus and discharge to a rehab facility are associated with increased risk of PJI. As the risk of PJI has not changed in 15 years, an appropriately powered trial is warranted to determine interventions that can improve infection rate after THA

The benefit of using acetabular screws in primary total hip arthroplasty (THA) has been questioned in recent years. The disadvantages of using screws include increased operative time, risk of injury to surrounding neurovascular structures and metal ware breakage. Recent large registry studies have reported that screws do not confer a protective effect against acetabular loosening or the presence of osteolysis. Other studies have even described an increased risk of aseptic acetabular loosening with the selective use of screws. We report findings from a multicentre cohort study. This large cohort study compared clinical outcomes between primary acetabular components that were inserted with and without screws. Independent variables included the presence (or absence) of screws, the total number of screws used and the cumulative screw length (CSL). Outcome measures included all-cause revision, acetabular component revision and acetabular component loosening. Statistical software (Stata/IC 13.1 for Mac [64-bit Intel]) was used to conduct all statistical analyses. A p-value < 0 .05 taken to be significant. There were 4,583 THAs performed in total. Screws were used in 15.9% (n=733). At a mean follow-up of 5.2 years, the all-cause revision rate in the screw cohort was 1.5% compared to 0.83% in the no screw cohort (p=0.085). There was no difference in acetabular component revision rates for screws (3/733, 0.41%) versus no screws (12/3,850, 0.31%) (p=0.439). The rate of acetabular loosening noted during the time of revision surgery was significantly higher when screws were used in the index procedure (2/733, 0.2%) compared to the no screw cohort (1/3,850, 0.02%) (p=0.017). There was no difference in outcomes when stratifying by the number of screws used or the cumulative screw length. Primary acetabular components do not require screws for fixation. All cause revision rates and acetabular component revision rates are comparable for the screw and the no screw cohorts. The rate of acetabular component loosening, as observed during revision surgery, is significantly higher when screws are used in the index total hip replacement

Aims. The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution. Methods. All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening. Results. The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years’ follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years’ follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%). Conclusion. The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368–375

To estimate the clinical and economic burden of primary total hip arthroplasty (THA) dislocation in England. Retrospective propensity score-matched evaluation of patients with and without dislocation following primary THA using the UK Clinical Practice Research Datalink linked and Hospital Episode Statistics datasets with a 2-year follow-up. 13,044 patients with total hip replacements met the inclusion criteria (mean age 69.2, 60.9% female) of which 154 (1.18%) suffered at least one postoperative hip dislocation. The mean number of dislocations per patient was 1.44 with a maximum of 4. Approximately one-third of the patients with dislocation (32.5%) had more than one dislocation. Among patients with a hip dislocation 148 patients (96.7%) had at least one closed reduction and 20 patients (13.1%) had revision surgery. Two-year median direct medical costs were £14,748 (95% confidence interval [CI] £12,028 to £20,638) higher with vs. without dislocation (+227%). On average, patients with a dislocation had significantly greater healthcare resource utilization and significantly less improvement in EuroQol-5D (EQ-5D) index (0.24 vs. 0.45; p<0.001) and Visual Analogue Scale (VAS) (1.58 vs. 11.23; p=0.010) scores and Oxford Hip Scores (13.02 vs. 21.98; p<0.001). This is the first study to estimate the economic burden of dislocation in the UK throughout the entire patient pathway. Dislocation following total hip replacement is a costly complication, both in terms of economic costs and to the functional quality of life of the patient. Efforts to reduce the risks of dislocation should remain at the forefront of hip research

Aims. 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. Methods. 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 (. Δ. sacral slope(SS). stand-sit. > 30°), or stiff (. ∆. SS. stand-sit. < 10°) spinopelvic mobility contributed to increased error rates. Results. The paired absolute difference between CAS and postoperative imaging measurements was 2.3° (standard deviation (SD) 2.6°) for inclination and 3.1° (SD 4.2°) for anteversion. Using a target zone of 40° (± 10°) (inclination) and 20° (± 10°) (anteversion), postoperative standing radiographs measured 96% of acetabular components within the target zone for both inclination and anteversion. Multiple logistic regression analysis controlling for BMI and sex revealed that hypermobile spinopelvic mobility significantly increased error rates for anteversion (odds ratio (OR) 2.48, p = 0.009) and inclination (OR 2.44, p = 0.016), whereas stiff spinopelvic mobility increased error rates for anteversion (OR 1.97, p = 0.028). There were no dislocations at a minimum three-year follow-up. Conclusion. Despite high reliability in acetabular positioning for inclination in a large patient cohort using an optical CAS system, hypermobile and stiff spinopelvic mobility significantly increased the risk of clinically relevant errors. In patients with abnormal spinopelvic mobility, CAS systems should be adjusted for use to avoid acetabular component misalignment and subsequent risk for long-term dislocation. Cite this article: Bone Jt Open 2022;3(6):475–484

Introduction. With the widespread legalization of cannabis across the United States, well-powered studies evaluating the impact of cannabis use disorder on outcomes following primary total hip arthroplasty are warranted. Therefore, the aim of this study was to determine whether cannabis use disorder has an effect on patients who undergo primary hip arthroplasty in terms of: 1) hospital lengths of stay (LOS); 2) medical complications; 3) implant-related complications; and 4) costs of care. Methods. Using an administrative database, patients who underwent primary total hip arthroplasty and had cannabis use disorder were matched to a cohort who did not in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 44,154 patients; 7,361 who had cannabis use disorder and 36,793 who did not. Variables for analysis included postoperative LOS, 90-day medical complications, 2-year implant-related complications, and 90-day costs of care. Mann-Whitney-U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. A p-value less than 0.005 was considered statistically significant. Results. The study found that patients who had cannabis use disorder had significantly longer in-hospital LOS (4 vs. 3 days, p<0.0001) compared to the matched cohort. Additionally, study patients were found to have significantly higher incidences and odds of developing medical (11.23 vs. 4.82%; OR: 1.47, p<0.0001) and implant-related complications (18.14 vs. 8.60%; OR: 1.50, p<0.0001). Moreover, patients who had cannabis use disorder incurred significantly higher 90-day episode of care costs ($24,585.96 vs. $23,725.93, p<0.0001). Conclusions. With the growing rates of cannabis use, this study can allow orthopaedists and other healthcare professionals to educate cannabis use disorder on the possible outcomes following their total hip arthroplasty. It should be appreciated that cannabis use disorder is associated with longer hospital stays, increased complication rates, and higher costs following primary THA

Objectives. High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA). Methods. We conducted a systematic review of studies evaluating surrogate markers for predicting long-term outcome in primary THA. Long-term outcome was defined as revision rate of an implant at ten years according to National Institute of Health and Care Excellence guidelines. We conducted a search of Medline and Embase (OVID) databases. Separate search strategies were devised for the Cochrane database and Google Scholar. Each search was performed to include articles from the date of their inception to June 8, 2015. Results. Our search strategy identified 1082 studies of which 115 studies were included for full article review. Following review, 17 articles were found that investigated surrogate markers of long-term outcome. These included one systematic review, one randomised control trial (RCT), one case control study and 13 case series. Validated surrogate markers included Radiostereometric Analysis (RSA) and Einzel-Bild-Röntgen-Analyse (EBRA), each measuring implant migration and wear. We identified five RSA studies (one systematic review and four case series) and four EBRA studies (one RCT and three case series). Patient Reported Outcome Measures (PROMs) at six months have been investigated but have not been validated against long-term outcomes. Conclusions. This systematic review identified two validated surrogate markers of long-term primary THA outcome: RSA and EBRA, each measuring implant migration and wear. We recommend the consideration of RSA in the pre-market testing of new implants. EBRA can be used to investigate acetabular wear but not femoral migration. Further studies are needed to validate the use of PROMs for post-market surveillance. Cite this article: T. T. Malak, J. A. J. Broomfield, A. J. R. Palmer, S. Hopewell, A. Carr, C. Brown, D. Prieto-Alhambra, S. Glyn-Jones. Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review. Bone Joint Res 2016;5:206–214. DOI: 10.1302/2046-3758.56.2000568

Aims. The aim of this study was to investigate whether the use of antibiotic-loaded bone cement influenced the risk of revision surgery after primary total hip arthroplasty (THA) for osteoarthritis. Methods. The study involved data collected by the National Joint Registry (NJR) for England and Wales, Northern Ireland and the Isle of Man between 1 September 2005 and 31 August 2017. Cox proportional hazards were used to investigate the association between use of antibiotic-loaded bone cement and the risk of revision due to prosthetic joint infection (PJI), with adjustments made for the year of the initial procedure, age at the time of surgery, sex, American Society of Anesthesiologists (ASA) grade, head size, and body mass index (BMI). We looked also at the association between use of antibiotic-loaded bone cement and the risk of revision due to aseptic loosening or osteolysis. Results. The cohort included 418,857 THAs of whom 397,896 had received antibiotic-loaded bone cement and 20,961 plain cement. After adjusting for putative confounding factors, the risk of revision for PJI was lower in those in whom antibiotic-loaded bone cement was used (hazard ration (HR) 0.79; 95% confidence interval (CI) 0.64 to 0.98). There was also a protective effect on the risk of revision due to aseptic loosening or osteolysis, in the period of > 4.1 years after primary THA, HR 0.57, 95% CI 0.45, 0.72. Conclusion. Within the limits of registry analysis, this study showed an association between the use of antibiotic-loaded bone cement and lower rates of revision due to PJI. The findings support the continued use of antibiotic-loaded bone cement in cemented THA. Cite this article: Bone Joint J 2020;102-B(8):997–1002

Aims. The primary aim of this trial was to compare the subsidence of two similar hydroxyapatite-coated titanium femoral components from different manufacturers. Secondary aims were to compare rotational migration (anteversion/retroversion and varus/valgus tilt) and patient-reported outcome measures between both femoral components. Methods. Patients were randomized to receive one of the two femoral components (Avenir or Corail) during their primary total hip arthroplasty between August 2018 and September 2020. Radiostereometric analysis examinations at six, 12, and 24 months were used to assess the migration of each implanted femoral component compared to a baseline assessment. Patient-reported outcome measures were also recorded for these same timepoints. Overall, 50 patients were enrolled (62% male (n = 31), with a mean age of 65.7 years (SD 7.3), and mean BMI of 30.2 kg/m. 2. (SD 5.2)). Results. The two-year subsidence was similar for Avenir (-0.018 mm (95% confidence interval (CI) -0.053 to 0.018) and Corail (0.000 mm (95% CI -0.027 to 0.026; p = 0.428). Both anteversion/retroversion (Avenir 0.139° (95% CI -0.204 to 0.481°); Corail -0.196° (95% CI -0.445 to 0.053°; p = 0.110) and varus/valgus tilt (Avenir -0.024° (95% CI -0.077 to 0.028); Corail -0.049° (95% CI -0.098 to 0.000°; p = 0.473) were not statistically significantly different. After two years, patients reported similar improvements in EuroQol five-dimension five-level health questionnaire (Avenir 0.22 (SD 0.2); Corail 0.22 (SD 0.18); p = 0.965) and other outcomes scores. Patient satisfaction on a five-point Likert scale was also similar between both groups after two years (Avenir 1.38 (SD 0.88); Corail 1.33 (SD 0.57); p = 0.846). Conclusion. The performance of both femoral components was similar in terms of stability and patient outcomes. Cite this article: Bone Joint J 2023;105-B(10):1045–1051

The last two decades have seen remarkable technological advances in total hip arthroplasty (THA) implant design. Porous ingrowth surfaces and highly crosslinked polyethylene (HXLPE) have been expected to dramatically improve implant survivorship. The purpose of the present study was to evaluate survival of contemporary cementless acetabular components following primary THA. 16,421 primary THAs performed for osteoarthritis between 2000 and 2019 were identified from our institutional total joint registry. Patients received one of 12 contemporary cementless acetabular designs with HXLPE liners. Components were grouped based on ingrowth surface into 4 categories: porous titanium (n=10,952, mean follow-up 5 years), porous tantalum (n=1223, mean follow-up 5 years), metal mesh (n=2680, mean follow-up 6.5 years), and hydroxyapatite (HA) coated (n=1566, mean follow-up 2.4 years). Kaplan-Meier analyses were performed to assess the survivorship free of acetabular revision. A historical series of 182 Harris-Galante-1 (HG-1) acetabular components was used as reference. The 15-year survivorship free of acetabular revision was >97% for all 4 contemporary cohorts. Compared to historical control, porous titanium (HR 0.06, 95% CI 0.02–0.17, p<0.001), porous tantalum (HR 0.09, 95%CI 0.03–0.29, p<0.001), metal mesh (HR 0.11, 95%CI 0.04–0.31, p<0.001), and HA-coated (HR 0.14, 95%CI 0.04–0.48, p=0.002) ingrowth surfaces had significantly lower risk of any acetabular revision. There were 16 cases (0.1%) of acetabular aseptic loosening that occurred in 8 (0.07%) porous titanium, 5 (0.2%) metal mesh, and 3 (0.2%) HA-coated acetabular components. 7 of the 8 porous titanium aseptic loosening cases occurred in one known problematic design. There were no cases of aseptic loosening in the porous tantalum group. Modern acetabular ingrowth surfaces and HXLPE liners have improved on historical results at the mid-term. Contemporary designs have extraordinarily high revision-free survivorship, and aseptic loosening is now a rare complication. At mid-term follow-up, survivorship of contemporary uncemented acetabular components is excellent and aseptic loosening occurs in a very small minority of patients

With the introduction of highly crosslinked polyethylene (HXLPE) in total hip arthroplasty (THA), orthopaedic surgeons have moved towards using larger femoral heads at the cost of thinner liners to decrease the risk of instability. Several short and mid-term studies have shown minimal liner wear with the use HXLPE liners, but the safety of using thinner HXPLE liners to maximize femoral head size remains uncertain and concerns that this may lead to premature failure exist. Our objective was to analyze the outcomes for primary THA done with HXLPE liners in patients who have a 36-mm head or larger and a cup of 52-mm or smaller, with a minimum of 10-year follow-up. Additionally, linear and volumetric wear rates of the HXLPE were evaluated in those with a minimum of seven-year follow-up. We hypothesized that there would be minimal wear and good clinical outcome. Between 2000 and 2010, we retrospectively identified 55 patients that underwent a primary THA performed in a high-volume single tertiary referral center using HXLPE liners with 36-mm or larger heads in cups with an outer diameter of or 52-mm or smaller. Patient characteristics, implant details including liner thickness, death, complications, and all cause revisions were recorded. Patients that had a minimum radiographic follow-up of seven years were assessed radiographically for linear and volumetric wear. Wear was calculated using ROMAN, a validated open-source software by two independent researchers on anteroposterior X-rays of the pelvis. A total of 55 patients were identified and included, with a mean age of 74.8 (range 38.67 - 95.9) years and a mean BMI of 28.98 (range 18.87 - 63-68). Fifty-one (94.4%) of patients were female. Twenty-six (47.7%) patients died during the follow-up period. Three patients were revised, none for liner wear, fracture or dissociation. Twenty-two patients had a radiographic follow-up of minimum seven years (mean 9.9 years, min-max 7.5 –13.7) and were included in the long-term radiographic analysis. Liner thickness was 5.5 mm at 45 degrees in all cases but one, who had a liner thickness of 4.7mm, and all patients had a cobalt-chrome head. Cup sizes were 52mm (n=15, 68%) and 50mm (n=7, 32%). Mean linear liner wear was 0.0470 mm/year (range 0 - 0.2628 mm) and mean volumetric wear was 127.69 mm3/year (range 0 - 721.23 mm3/year). Using HXLPE liners with 36-mm heads or bigger in 52-mm cups or smaller is safe, with low rates of linear and volumetric wear in the mid to long-term follow-up. Patients did not require revision surgery for liner complications, including liner fracture, dissociation, or wear. Our results suggest that the advantages of using larger heads should outweigh the potential risks of using thin HXLPE liners

Aims. The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA). Methods. Patients waiting for a THA (n = 100) or KA (n = 100) for more than six months were prospectively recruited from the study centre. Overall,162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five-dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected. Results. There was a significant correlation between CFS and the Oxford score (THA r = −0.838; p < 0.001, KA r = −0.867; p < 0.001), EQ-5D index (THA r = −0.663, p =< 0.001; KA r = −0.681; p =< 0.001), and EQ-VAS (THA r = −0.414; p < 0.001, KA r = −0.386; p < 0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p < 0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p < 0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p < 0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p < 0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B = −11.5; p < 0.001, KA B = −7.9; p = 0.005) was also associated with CFS. Conclusion. JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists. Cite this article: Bone Jt Open 2023;4(4):241–249

Aims. Septic arthritis of the hip often leads to irreversible osteoarthritis (OA) and the requirement for total hip arthroplasty (THA). The aim of this study was to report the mid-term risk of any infection, periprosthetic joint infection (PJI), aseptic revision, and reoperation in patients with a past history of septic arthritis who underwent THA, compared with a control group of patients who underwent THA for OA. Methods. We retrospectively identified 256 THAs in 244 patients following septic arthritis of the native hip, which were undertaken between 1969 and 2016 at a single institution. Each case was matched 1:1, based on age, sex, BMI, and year of surgery, to a primary THA performed for OA. The mean age and BMI were 58 years (35 to 84) and 31 kg/m. 2. (18 to 48), respectively, and 100 (39%) were female. The mean follow-up was 11 years (2 to 39). Results. The ten-year survival free of any infection was 91% and 99% in the septic arthritis and OA groups, respectively (hazard ratio (HR) = 13; p < 0.001). The survival free of PJI at ten years was 93% and 99% in the septic arthritis and OA groups, respectively (HR = 10; p = 0.002). There was a significantly higher rate of any infection at ten years when THA was undertaken within five years of the diagnosis of septic arthritis compared with those in whom THA was undertaken > five years after this diagnosis was made (14% vs 5%, respectively; HR = 3.1; p = 0.009), but there was no significant difference in ten-year survival free of aseptic revision (HR = 1.14; p = 0.485). The mean Harris Hip Scores at two and five years postoperatively were significantly lower in the septic arthritis group compared with the OA group (p = 0.001 for both). Conclusion. There was a ten-fold increased risk of PJI in patients with a history of septic arthritis who underwent THA compared with those who underwent THA for OA with a ten-year cumulative incidence of 7%. The risk of any infection had a strong downward trend as the time interval between the diagnosis of septic arthritis and THA increased, highlighted by a 3.1-fold higher risk when THAs were performed within five years of the diagnosis being made. Cite this article: Bone Joint J 2022;104-B(2):227–234

Aims. Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks. Materials and Methods. The data included all primary THA procedures performed for osteoarthritis (OA), reported to the AOANJRR between 01 September 1999 and 31 December 2014. There were 9289 femoral stems with an exchangeable neck and 253 165 femoral stems with a fixed neck. The characteristics of the patients and prostheses including the bearing surface and stem/neck metal combinations were examined using Cox proportional hazard ratios (HRs) and Kaplan-Meier estimates of survivorship. . Results. It was found that prostheses with an exchangeable neck had a higher rate of revision and this was evident regardless of the bearing surface or the size of the femoral head. Exchangeable neck prostheses with a titanium stem and a cobalt-chromium neck had a significantly higher rate of revision compared with titanium stem/titanium neck combinations (HR 1.83, 95% confidence interval 1.49 to 2.23, p < 0.001). Revisions were higher for these combinations compared with femoral stems with a fixed neck. Conclusion . There appears to be little evidence to support the continued use of prostheses with an exchangeable neck in primary THA undertaken for OA. Cite this article: Bone Joint J 2017;99-B:766–73

Aim. To study whether revision for prosthetic joint infection (PJI) after early PJI in primary Total Hip Arthroplasty (THA) is associated with a high mortality, when compared with:. Patients, who did not undergo revision for any reason and Patients who underwent an aseptic revision. Method. This population-based cohort study was based on the Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. Results. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of follow-up, or, in case of a revision, 1 year from the date of revision. Within 1 year of primary THA, 8% (95% CI, 6%–11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54–3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (9f5% CI, 1.11–3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66–5.81) higher mortality risk than patients infected with other bacteria (p < 0.001). Conclusions. Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. Especially enterococci-infected THA have a high motrtaly risk

Dislocation after Total Hip Arthroplasty (THA) is a frequent cause of revision and patients with intrinsic risk factors have been identified. The use of dual mobility (DM) cup has shown great efficiency in preventing dislocation, with questions regarding selective or absolute use. The aim of this study was to compare the outcome of single mobility THA (SM-THA) and DM-THA, when used for selected patients. This retrospective continuous cohort study evaluated 490 patients of whom 275 received SM-THA and 215 received DM-THA. There were 304 primary osteoarthritis (62%), 121 femoral neck fractures (24%) and 65 other indications (14%). The surgical approach was anterior (AA) in 79% and posterior (PA) in 21% of cases. In the DM-THA group, 189 patients (87%) presented at least one dislocation risk factor compared to 128 patients (46%) in the SM-THA group. The primary outcome was revision for all causes, with or without implant removal. Secondary outcomes included length of hospital stay. There was no difference in all cause revision at two years follow up with 9 procedures (3.2%) in SM-THA group and 11 in DM-THA group (5.1%) (p=0.3). There were 3 dislocations in SM-THA group (3 AA) and 3 in DM-THA group (2 PA and 1 AA) (p=0.4). The length of stay was significantly longer in DM-THA group with 7 days (2–12) compared to 4 days (1–7) in SM-THA group (p=0.001). SM-THA and DM-THA are two complementary devices in the management of patients requiring primary THA. SM-THA is a safe option for patients without dislocation risk factors, especially when using AA. The identification of such factors is important to select patients requiring DM-THA and provide reproducible outcomes in a University Hospital practice including various levels of surgeon experience

Background. Uncemented dual-tapered stems are a popular choice for primary total hip arthroplasty (THA). The purpose of this study was to examine long-term outcomes after primary THA utilizing a single dual-tapered stem. Patients and Methods. Utilizing our total joint registry, we retrospectively identified 1215 THAs (1055 patients) performed with an uncemented dual-tapered stem from 1998 to 2009. Mean age was 55 years, 70% were male, and mean BMI was 30 kg/m. 2. Mean follow-up was 10 years. Analysis included implant survivorship, clinical outcomes, and radiographic results. Results. Survivorship from stem revision for any reason was 99.0% at 5 years postoperatively and 98.4% at both 10 and 15 years. Survivorship from stem revision for aseptic loosening was 99.9% at 5-, 10-, and 15-years postoperatively. Survivorship from stem revision for periprosthetic fracture was 99.7%, 99.1%, and 98.9% at 5, 10, and 15 years postoperatively, respectively. In total, 18 (1.5%) stems underwent revision. Revisions were performed for periprosthetic fracture (10, 0.82%), infection (7, 0.58%), and aseptic loosening (1, 0.08%). Intraoperative fracture occurred in 58 (4.77%) THAs treated with cerclage wiring (52, 89.66%) or no treatment (6, 10.34%) and insertion of a standard prosthesis. At mean radiographic follow-up of 10 years, only 4 of 1084 (0.37%) stems with 1-year radiographic follow-up had any radiolucency around the proximal ongrowth coating, and only 1 (0.10%) of these had a circumferential radiolucent line (Gruen zones 1–14). Conclusions. This uncemented dual-tapered femoral stem is associated with excellent survivorship, reasonably low intraoperative fracture rate, and extremely low rates of revision for aseptic loosening, periprosthetic fracture, and infection when used for primary THA at long-term follow up. For any tables or figures, please contact the authors directly

Aims. Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA. Patients and Methods. We identified 84 patients (97 THAs) between 1998 and 2015 who had undergone spinal fusion prior to primary THA. Patients were stratified into three groups depending on the length of lumbar fusion and whether or not the sacrum was involved. Mean age was 71 years (40 to 87) and 54 patients (56%) were female. The mean body mass index (BMI) was 30 kg/m. 2. (19 to 45). Mean follow-up was six years (2 to 17). Patients were 1:2 matched to patients with primary THAs without spine fusion. Hazard ratios (HR) were calculated. Results. Dislocation in the fusion group was 5.2% at one year versus 1.7% in controls but this did not reach statistical significance (HR 1.9; p = 0.33). Compared with controls, there was no significant difference in rate of dislocation in patients without a sacral fusion. When the sacrum was involved, the rate of dislocation was significantly higher than in controls (HR 4.5; p = 0.03), with a trend to more dislocations in longer lumbosacral fusions. Patient demographics and surgical characteristics of THA (i.e. surgical approach and femoral head diameter) did not significantly impact risk of dislocation (p > 0.05). Significant radiological differences were measured in mean anterior pelvic tilt between the one-level lumbar fusion group (22°), the multiple-level fusion group (27°), and the sacral fusion group (32°; p < 0.01). Ten-year survival was 93% in the fusion group and 95% in controls (HR 1.2; p = 0.8). Conclusion. Lumbosacral spinal fusions prior to THA increase the risk of dislocation within the first six months. Fusions involving the sacrum with multiple levels of lumbar involvement notably increased the risk of postoperative dislocation compared with a control group and other lumbar fusions. Surgeons should take care with component positioning and may consider higher stability implants in this high-risk cohort

Introduction. Patients undergoing primary total hip arthroplasty (THA) with prior lumbar spine fusion (LSF) are at high risk for instability with reported incidence of dislocation as high as 8.3%. The use of dual mobility cups in patients undergoing revision THA, another high risk group, has demonstrated decreased incidence of instability. Purpose of this study was to evaluate the risk of instability in patients undergoing primary THA with a history of prior LSF using dual mobility cups. Methods. This was a multi-center retrospective study with 93 patients undergoing primary THA using a dual mobility cup with prior history of instrumented LSF. The primary outcome investigated was instability. Secondary variables investigated included number of levels fused, approach, length of stay, and other complications. The minimum follow-up time was 1 year since the majority of dislocations occur during first year following the primary THA. Results. There were 56 females and 47 males with average age of 66 years (46–87) and average BMI of 30. Mean follow up was 31 months (range 12 – 124.2). Surgical approach included: posterior (63), direct lateral (15), anterior (11), direct superior (4). 44% had one level fusion, 29% with 2 levels, and 15% with 3 or more levels fused. There were no dislocations or infections in this study group. There was one intraoperative fracture and one DVT. Conclusions. Patients undergoing primary THA with prior LSF are a high risk group with an increased risk for instability due to the loss of normal spino-pelvic relationship. The use of dual mobility cups in a high risk group of patients in this study demonstrated excellent results with no incidence of dislocation. Despite the limitations in this study with varying approaches and multiple sites, the use of dual mobility cups to decrease the incidence of instability in patients with prior LSF appears promising. For any tables or figures, please contact the authors directly

The aim of this study is the comparative assessment of long term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA. 122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford hip score (OHS), Short form-12 health survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, timed up and go test (TUG), Parker mobility, Lower extremity function score (LEFS) and UCLA scores. At a mean follow up of 14.4 years (10 to 20) a cumulative success rate of 96% (95% CI 96 to 99%) in Group A and 98% (95% CI 97 to 99%) in Group B with operation for any reason as an end point was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U test, p= 0.014), OHS (Mann-Whitney U test, p= 0.020) and physical component of SF-12 scores (Mann-Whitney U test, p= 0.029) only. In Group A, in multiple regression analysis, patients’ cognition (p=0.001), BMI (p=0.007) and pain (p=0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p=0.03) was found to influence quality of life (EQ-5D-5). In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes

Introduction. Registry data from around the world demonstrates instability following primary THA is a leading indication for revision. However, the burden of THA dislocation is poorly documented and is not routinely recorded or reported at a national level. Our aim was to determine the rate of dislocation following primary THA in contemporary practice and in doing so determining the burden of THA dislocation to the NHS in Wales. Method. We considered all Welsh residents who underwent primary THA from 2011–2016. Via clinical coding linkage using Patient Episode Database for Wales (PEDW), the equivalent of HES data in England, we were able determine re-admission for dislocation, revision THA following dislocation and all cause revision at 1 to 5 years follow-up. Results. In a cohort of 20,816 primary THA the dislocation rate at 1-year follow-up was 1.1% (95%CI 0.97–1.25). This increased incrementally to 2.2% (95%CI 1.78–2.72) at 5 years. At 1 year the overall revision rate was 1.3% of which 0.3% was following instability. The median time to dislocation was 46 days and 67.8% of first time dislocations occurred within 6 months of index surgery. We undertook a clinical coding data validation for a sub-group of 2,677 THA procedures, cross-referencing hospital records and theatre logbooks with PEDW data and demonstrated a correlation of 90.6% (95%CI 75.8–96.8). We observed 229 first time dislocation events, but during the total study period there were 1179 emergency admissions for dislocated THA with a mean hospital length of stay of 5.5 days. Discussion & Conclusions. This study provides benchmarking data at a national level regarding the risk of dislocation for patients undergoing primary THA. Importantly it demonstrates the significant accumulative burden of dislocation following THA for both patients and impact on NHS resources

Background. The impact of a patient's activity level following total hip arthroplasty (THA) remains controversial, with some concerned about increased polyethylene wear, aseptic loosening and revisions. The purpose of this study is to report on implant survivorship and outcomes of high activity patients compared to low activity patients after THA with current polyethylene. Methods. A retrospective review identified 2002 patients (2532 hip) that underwent a primary THA with vitamin E infused highly crosslinked polyethylene liner and 2-year minimum follow-up or revision. Patients were divided in two groups based on their University of California Los Angeles (UCLA) activity level: Low activity (LA) (UCLA ≤5) and high activity (HA) (UCLA ≥ 6). Outcomes included Harris Hip Score, UCLA activity score, complications and reoperations. Multivariate nominal regression analysis was performed to evaluate the significance of postoperative activity level on survivorship while controlling for age, gender, preoperative pain, HHS and body mass index (BMI). Results. Mean follow-up was 4.5 years (range, 0.3 to 9.9 years). The LA group had significantly more female patients, were older, higher BMI and lower HHS pre-operatively (all with p<0.001). HA group had significantly higher improvements in HHS (p<0.001) and UCLA activity score (p<0.001). Aseptic revisions were performed in 2.1% of the LA group and in 0.4% hips of the HA group (p<0.001). Multivariate regression analysis found that a higher postoperative activity level remained a significant factor for improved aseptic survivorship with an OR of 4.9 (95% CI, 1.1 to 21.2, p=0.03). The aseptic 5-year survivorship was 99.6% for the HA group and 98% for the LA group (p<0.001). Conclusions. Higher activity level after primary THA did not increase the risk for midterm aseptic or all cause failure. Patient activity level after THA may not need to be limited with modern polyethylene

Introduction. The results of repair and reconstruction of lesions found in the abductor muscles and tendons during posterior approach to primary total hip arthroplasty (THA) were reported in 2018. During the course of this series it became apparent that the extent of damage in the abductor tendons and muscles usually was obscured by the hypertrophic greater trochanteric bursa, especially the deep layer adherent to the greater trochanter and abductor muscles. The purpose of this study was to evaluate the surgeon's ability to see these lesions during standard posterior approach, and also to describe the dissection necessary to fully expose them. Patients and Methods. A total of 525 patients (525 hips) underwent primary THA through posterior approach between 2009 and 2013. Fifty-four patients had mild chronic damage to the tendon. Forty-one patients had severe damage with major avulsion of the gluteus medius and minimus muscles. Results. None of the hips with normal abductor muscle structure had a dense trochanteric bursa to obscure the abductor attachment to bone, but in 35 hips (85.3%) with significant abductor tendon avulsion, the lesions in the tendons were hidden from view until the greater trochanteric bursa was dissected. Splitting the deep layer of the trochanteric bursa in line with the fibers of the abductor muscles was necessary to reveal avulsion of the tendons from the edge of the greater trochanter. Only six hips (14.6%) had abductor tendon avulsion from the greater trochanter that could be seen without removing the trochanteric bursa tissue. Conclusion. The posterior approach offered excellent exposure of the abductor mechanism during primary THA, but the avulsion defects in the gluteus medius and minimus muscles remained obscured until the outer layer of the greater trochanteric bursa was completely removed and the deep fibrous layer was dissected adequately to expose the tendon attachment to bone. For any tables or figures, please contact the authors directly

Aims. The purpose of this study is to evaluate early outcomes with the use of a smartphone-based exercise and educational care management system after total hip arthroplasty (THA) and demonstrate decreased use of in-person physiotherapy (PT). Methods. A multicentre, prospective randomized controlled trial was conducted to evaluate a smartphone-based care platform for primary THA. Patients randomized to the control group (198) received the institution’s standard of care. Those randomized to the treatment group (167) were provided with a smartwatch and smartphone application. PT use, THA complications, readmissions, emergency department/urgent care visits, and physician office visits were evaluated. Outcome scores include the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), health-related quality-of-life EuroQol five-dimension five-level score (EQ-5D-5L), single leg stance (SLS) test, and the Timed Up and Go (TUG) test. Results. The control group was significantly younger by a mean 3.0 years (SD 9.8 for control, 10.4 for treatment group; p = 0.007), but there were no significant differences between groups in BMI, sex, or preoperative diagnosis. Postoperative PT use was significantly lower in the treatment group (34%) than in the control group (55.4%; p = 0.001). There were no statistically significant differences in complications, readmissions, or outpatient visits. The 90-day outcomes showed no significant differences in mean hip flexion between controls (101° (SD 10.8)) and treatment (100° (SD 11.3); p = 0.507) groups. The HOOS, JR scores were not significantly different between control group (73 points (SD 13.8)) and treatment group (73.6 points (SD 13); p = 0.660). Mean 30-day SLS time was 22.9 seconds (SD 19.8) in the control group and 20.7 seconds (SD 19.5) in the treatment group (p = 0.342). Mean TUG time was 11.8 seconds (SD 5.1) for the control group and 11.9 (SD 5) seconds for the treatment group (p = 0.859). Conclusion. The use of the smartphone care management system demonstrated similar early outcomes to those achieved using traditional care models, along with a significant decrease in PT use. Noninferiority was demonstrated with regard to complications, readmissions, and ED and urgent care visits. This technology allows patients to rehabilitate on a more flexible schedule and avoid unnecessary healthcare visits, as well as potentially reducing overall healthcare costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):91–97

Aims. Only a small number of studies exist that report the results of EBM-produced porous coated trabecular titanium cups in primary total hip arthroplasty (THA). This study aims to investigate the patient satisfaction level, clinical function and radiographic outcomes of the patients who underwent THA using an EBM-produced porous coated titanium cup. Patients and Methods. A total of 32 patients who underwent primary THA with using an EBM-produced porous coated titanium cup from five hospitals between May and December, 2012 were retrospectively reviewed. Five patients were lost prior to the minimum 6-year follow-up. Clinical and radiographic outcomes were analyzed with an average follow-up of 81.48 (range: 77.00–87.00) months. Results. The median HHS and SF-36 scores improved significantly while the WOMAC Osteoarthritis Index decreased significantly at the latest follow-up (p<0.001). Eighteen (66.7%) patients rated their satisfaction level as very satisfied, 6 (22.2%) as satisfied, 2 (7.4%) as neutral and 1(3.7%) as dissatisfied. No intraoperative or postoperative complications were identified, including aseptic cup loosening, hip dislocation, periprosthetic joint infection, periprosthetic fracture, nerve palsy, hematoma. At the latest follow-up, all cups were considered to have achieved fixation via bone ingrowth with three or more of the five signs occurring in the most recent X-ray. However, three cups revealed radiolucent lines with a width of less than 1 mm. These radiolucent lines were distributed in the DeLee-Charnley zone 1 in 1 patient, zone 3 in another patient and the area between zone1 and zone 2 in an additional patient. The latest postoperative centers of rotation were restored nearly to the anatomic center of rotation both vertically and horizontally and the acetabular cups obtained satisfactory orientation postoperatively. Conclusions. The mid-term follow-up of patients who underwent primary THA using EBM-produced porous coated titanium cups demonstrated favorable patient satisfaction, clinical function and adequate biological fixation. For any figures or tables, please contact authors directly

Aims. The aim of this study was to estimate the 90-day risk of revision for periprosthetic femoral fracture associated with design features of cementless femoral stems, and to investigate the effect of a collar on this risk using a biomechanical in vitro model. Materials and Methods. A total of 337 647 primary total hip arthroplasties (THAs) from the United Kingdom National Joint Registry (NJR) were included in a multivariable survival and regression analysis to identify the adjusted hazard of revision for periprosthetic fracture following primary THA using a cementless stem. The effect of a collar in cementless THA on this risk was evaluated in an in vitro model using paired fresh frozen cadaveric femora. Results. The prevalence of early revision for periprosthetic fracture was 0.34% (1180/337 647) and 44.0% (520/1180) occurred within 90 days of surgery. Implant risk factors included: collarless stem, non-grit-blasted finish, and triple-tapered design. In the in vitro model, a medial calcar collar consistently improved the stability and resistance to fracture. Conclusion. Analysis of features of stem design in registry data is a useful method of identifying implant characteristics that affect the risk of early periprosthetic fracture around a cementless femoral stem. A collar on the calcar reduced the risk of an early periprosthetic fracture and this was confirmed by biomechanical testing. This approach may be useful in the analysis of other uncommon modes of failure after THA. Cite this article: Bone Joint J 2019;101-B:779–786

Background. Over 35% of surgeons in the United States, and 10% in Canada use the direct anterior approach for primary total hip arthroplasty (THA). Some of the key barriers in its wider adoption are the learning curve and associated increased risk of adverse events. The purpose of this study was to determine the adoption rate as well as 90-day re-admission and adverse event of the anterior approach in a community-based hospital. Methods. From December 2015 to August 2018, two laterally based approach senior orthopaedic surgeons with over 20 years of practice performed 319 primary total hip replacements, with 164 being done through the anterior approach and 155 through the lateral approach. All but 8 of the anterior approaches were done on a regular operating table. Results. The anterior and lateral approach groups were comparable in age with mean 69.1+/− 10.2 and 68.9+/−9.3, respectively (p= 0.886), however the anterior group had patients with a statistically significantly lower BMI than the lateral group with mean 28.2+/−5.4 and 31.0+/−6.3, respectively (p < 0.001). Furthermore, there was a much lower percentage of females in the anterior group than in the lateral group with 49.4% and 65.2%, respectively (p= 0.004). It took surgeon A and B 12 and 24 months for the anterior approach to represent over 50% of their monthly cases, respectively. The anterior approach now accounts for approximately 80% of surgeon A's practice and 100% in surgeon B's practice in the last 6 and 18 months, respectively. Intraoperative adverse events were comparable between anterior and lateral approaches, with one incidence in each group (p= 0.968), however post-operative adverse events were more prevalent in the lateral group (n= 24) when compared to anterior group (n= 11) (p= 0.012). Further details of both approaches are provided in figure 1. Conclusion. Within a well-structured environment, the anterior approach can be safely introduced into a community-based practice. The progressive adoption of a new surgical technique combined with more experienced surgeon as a resource is an effective way that requires further study. For any figures or tables, please contact the authors directly

Total hip arthroplasty has been constantly evolving with technological improvements to achieve the best survival rates. Although the new implants are under closer surveillance through processes such as Beyond Compliance, orthopaedic surgeons generally tend to look out for the latest implants with good short-term results and hope for better long-term results for these. We questioned whether such an assumption or bias is valid. We analysed the data of Kaplan-Meier estimates of cumulative revisions of primary hip replacement by fixation, stem/cup brand and bearing combinations from the NJR 19th Annual Report published in September 2022. We performed a univariate linear regression analysis to predict the 10- and 15-year revision rates for these different hip implant combinations from the 3- and 5-year revision rates. Thirty-seven implant combinations had their 15-year revision rates reported and 67 had the 10-year revision rates. The correlation co-efficients were 0.43 and 0.58 for the 3-year and 5-year revision rates against 15-year revision rates. Only 17% of the variance in 15-year revision rates could be predicted by a linear regression model from the 3-year revision rate and 32% from the 5-year revision rate. Corresponding values for the 10-year revision rates were 46% and 67%. 95% prediction intervals for the 15-year revision rate were +/− 3.1% from the 3-year revision rate and +/− 2.8% from the 5-year revision rate. Corresponding values for the 10-year revision rates were +/− 1.3% and +/− 1%. 19 of 37 implant combinations showed 15-year revision rate of more than 4%. Average 3-year and 5-year revision rates for this cohort was 1.0% and 1.42% compared to 1.4% and 1.9% for the rest and the difference was statistically significant. Although average early revision rates showed small but significant difference between the groups with lower and higher 15-year revision rates, the prediction intervals for 15-year revision rates for individual hips based on their 3-year and 5-year revision rates are very wide. Three- and 5-year revision rates for primary total hip replacements are poor predictors of 15-year revision rates

Introduction. Previous registry studies of ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) have focused on revision outcomes following primary surgery. Less is known about the effect of ceramic bearings on infection, dislocation, and mortality as outcomes following primary total hip arthroplasty (THA) for the Medicare population. We asked (1) does the use of C-PE bearings influence outcomes following THA as compared with metal-on-polyethylene (M-PE); and (2) does the use of COC bearings influence outcomes following THA as compared with M-PE?. Methods. A total of 315,784 elderly Medicare patients (65+) who underwent primary THA between 2005 and 2014 with known bearing types were identified from the Medicare 100% inpatient sample administrative database. Outcomes of interest included relative risk of 90-day readmission, infection, dislocation, revision, or mortality at any time point after primary surgery. Propensity scores were developed to adjust for selection bias in the choice of bearing type at index primary surgery. Cox regression incorporating propensity score stratification (10 levels) was then used to evaluate the impact of bearing surface selection on outcomes, after adjusting for patient-, hospital-, and surgeon-related factors. Results. For primary THA patients treated with C-PE bearings and COC bearings, there was significantly reduced risk of infection relative to M-PE bearings (C-PE Hazard Ratio, HR: 0.86, p=0.001; COC Hazard Ratio, HR: 0.74, p=0.01). For the C-PE cohort, we also observed reduced risk of 90-day readmission (HR: 0.94, p<0.001); dislocation (HR: 0.81, p<0.001); and mortality (HR: 0.92, p<0.001). There was no significant difference in risk of revision for either the C-PE or COC bearing cohorts when compared with M-PE. For the COC cohort, there was no significant difference in readmission, dislocation, or mortality risk. Conclusions. The results indicate that, after adjusting for selection bias and various confounding patient-, surgeon-, and hospital-related factors, Medicare patients treated with primary THA with ceramic bearings exhibit lower risk of infection than those treated with M-PE bearings. In addition, C-PE bearings were associated with lower risk of dislocation and mortality. As in previous registry studies, we found that ceramic bearings have similar revision risk as M-PE bearings in primary THA at between 8 and 9 years of follow-up. The findings of this study support further research into the long-term association between ceramic bearings in primary THA and clinical outcomes

Background. The purpose of this study is to evaluate the early outcomes with the use of a smartphone-based exercise and educational platform after primary total hip arthroplasty compared to a standard of care control group. Methods. A multicenter prospective randomized control trial was conducted evaluating the use of the mymobility smartphone-based care platform for primary total hip arthroplasty (THA). Patients randomized to the control group (198 patients) received the respective institution's standard of care. Those randomized to mymobility treatment group (167 patients) were provided an Apple Watch and mymobility smartphone application. The application provides pre and postoperative educational content, video directed exercise programs as well as tracks the patient's activity. Patients in the treatment group were not initially prescribed physical therapy, but could be if their surgeon deemed it necessary. Early outcomes assessed included 90-day hip range of motion, HOOS JR scores, 30-day single leg stance (SLS) and time up and go (TUG) test. We also evaluated PT utilization, THA complications associated with readmissions, ER visits not associated with readmissions, urgent care (non standard of care) visits, and physician office visits. Outcome scores include HOOS-Jr, EQ-5D-5L, single stance (SLS), Timed up and go (TUG). Satisfaction scores for the procedure and the mymobility study group were also recorded. Results. The control group was significantly younger by 3.0 years (p=0.007), but no significant difference between groups in BMI, gender or preoperative diagnosis. Postoperative PT utilization was statistically lower in the mymobility group. (P=.001). There were no statistically significant differences in complications, readmissions, or office visits. The 90-day outcomes showed no significant differences in hip flexion between controls (101.3±10.9) and mymobility (99.8 ±12) (p=0.34). HOOS JR scores were not significantly different between control group (84 ±14.5) and mymobility group (81 ±13) (p=0.15). Mean 30-day SLS time was 22.5 ±20 sec in the control group and 19.8 ±19 sec in the mymobility group (p=0.25). Mean TUG time was 14.1 ±27.4 sec for control group and 16.1 ±43.3 sec for my mobility group (p=0.7). Conclusion. The use of the mymobility care platform demonstrated similar early outcomes to traditional care models. This study showed a significant decrease in PTA utilization. Initial findings demonstrated non inferiority of the mymobility platform with regards to complications, readmissions, emergency room and urgent care visits. Strengths of this study include randomized, multicentered study design. Both groups were balanced except for age. Weakness of this study is the lack of preoperative functional testing which may influence postoperative single stance. This technology allows patients to rehabilitate on a more flexible schedule, avoid unnecessary healthcare visits as well as potentially decrease overall healthcare costs

Introduction. There is renewed interest in dislocation after surgical approach with popularization of the direct anterior approach. The purported advantage of both the lateral and direct anterior approaches is decreased risk of dislocation. The purpose of this study was to assess the risk of dislocation by approach following modern primary THA. Methods. All primary THAs at a single academic institution from 2010 to 2017 were analyzed through our institutional total joint registry. There were 7023 THAs including 3754 posterior, 1732 lateral, and 1537 direct anterior. Risk of dislocation was assessed against the competing risks of revision surgery and death as well as by individual patient and surgical factors including surgical approach. Risk of revision surgery was considered as a secondary outcome. Step-wise selection was utilized to develop multivariable models. Clinical outcomes were documented with the Harris Hip Score (HHS). Mean age was 63 years, 51% were female, and mean body mass index (BMI) was 30 kg/m. 2. Minimum follow-up was 2 years. Results. The cumulative incidence of dislocation at 1-year and 5-years by approach was as follows: posterior (2.1%; 3.0%), lateral (0.7%; 0.7%), direct anterior (0.4%; 0.4%) (p<0.001) (Figure 1). Compared to the posterior cohort, the adjusted risk of dislocation was decreased for the lateral (hazard ratio [HR]=0.28, p<0.001) and direct anterior cohorts (HR=0.18, p<0.001). The cumulative incidence of revision for instability at 1-year and 5-years by approach was as follows: posterior (0.8%; 1.0%), lateral (0.6%; 0.6%), direct anterior (0%; 0%) (p=0.09). The adjusted risk of all-cause revision surgery was increased among the lateral cohort compared to posterior (HR=1.75, p=0.003) and direct anterior (HR=2.44, p=0.002) and among patients with diagnoses other than osteoarthritis (HR=2.89, p<0.001). Among patients who dislocated, 69 (83%) had anteversion >25° (Figure 2). Mean increase in HHS from preoperative assessment to final follow-up was greatest among direct anterior patients (37 points), followed by posterior patients (33 points), followed by lateral patients (29 points) (p<0.05, all comparisons). Conclusions. This study documents the risk of dislocation by surgical approach among a large contemporary cohort undergoing primary THA. The risk of dislocation was higher following the posterior approach, whereas all-cause revision surgery was found to be higher following the lateral approach. For any tables or figures, please contact the authors directly

Despite the widespread success of total hip arthroplasty (THA), postoperative pain management remains a concern. Opioids have classically been administered for pain relief after THA, but their side effect profile, in addition to the cognizance of the growing opioid epidemic, has incited a shift toward alternative pain modalities. Although the nonsteroidal anti-inflammatory drug (NSAID) diclofenac is a promising addition, its impact on immediate THA outcomes has not previously been investigated. Thus, in the present study, we evaluate the effects of adjunctive diclofenac on: 1) postoperative pain intensity, 2) opioid consumption, 3) discharge destination, 4) length of stay, and 5) patient satisfaction in primary THA patients. A retrospective review was performed to identify all patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients were stratified into a study group (n=25), who were treated with postoperative diclofenac in addition to the standard pain control regimen, and a control group (n=88), who did not receive adjunctive diclofenac. Repeated-measures analysis of variance (ANOVA)/analysis of covariance (ANCOVA) and chi-square/logistic regression analysis were used for continuous and categorical variables, respectively. Patients receiving adjunctive diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02, p=0.049). In addition, patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the diclofenac group. Finally, patients who received diclofenac had lower opioid consumption on postoperative days one and two (−67.2 and −129 mg, respectively, p=0.001 for both). The rapid growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. The present study demonstrates that THA patients receiving adjunctive diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. This will, in turn, decrease complications and total hospital costs, leading to a more cost-effective pain control regimen. In order to further investigate the optimal regimen, future studies comprising larger cohort, as well as a comparison of diclofenac to other NSAIDs, are warranted

Aims. We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. Patients and Methods. This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression. Results. Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery versus uncomplicated THA (p < 0.001). Conclusion. IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: Bone Joint J 2019;101-B:1199–1208

Modular femoral stems offer surgeons great flexibility in biomechanical configuration during total hip replacement (THR) however introduce a taper-trunnion articulation known to be a source of additional wear debris through crevice, fretting and galvanic corrosion with mixed material combinations. This study aimed to investigate the influence of the trunnion bearing surface combination on the revision rate following primary total hip replacement (THR). All patients who underwent THR using an Exeter V40 cemented stainless steel stem and monobloc cemented polyethylene acetabular component (uncemented cups excluded to standardise the acetabular bearing surface and fixation) between January 2003 and December 2019 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. The primary exposure was the head substrate used corresponding to the trunnion bearing. Time-to-event was determined by duration of implantation from primary surgery to revision with cases censored at death or end of available follow-up. Multivariable Cox proportional hazard models were used to identify predictors of all cause revision, adjusted for age, sex, American Association of Anaesthesiologists (ASA) grade, body mass index, surgical indication (osteoarthritis or other), and femoral head size. 229,870 THR were identified (66% female, mean age 73.4 years (SD 9.1) with the majority (91%) performed for osteoarthritis of which 4,598 were revised. Mean time from primary to revision or censoring was 6.8 years (SD 4.0). Multivariable modelling showed CoCr/SS trunnions were associated with a significantly higher risk of revision (hazard ratio (HR) 1.31 (95%CI 1.15 to 1.48, p<0.0001) as compared to SS/SS (reference). Both Alumina/SS (HR 0.74 (0.65 to 0.84), p<0.0001) and Zirconia/SS (HR 0.61 (0.49 to 0.74), p<0.0001) were associated with a significantly lower risk of revision. Ceramic heads on an Exeter stem were associated with significantly improved survivorship compared to metal heads in primary THR. CoCr/SS trunnion articulations had the poorest survivorship which may be contributed to by trunnionosis

We examined the association between patient-related factors and the risk of initial, short- and long-term implant failure after primary total hip replacement. We used data from the Danish Hip Arthroplasty Registry between 1 January 1995 and 31 December 2002, which gave us a total of 36 984 patients. Separate analyses were carried out for three follow-up periods: 0 to 30 days, 31 days to six months (short term), and six months to 8.6 years after primary total hip replacement (long term). The outcome measure was defined as time to failure, which included re-operation with open surgery for any reason. Male gender and a high Charlson co-morbidity index score were strongly predictive for failure, irrespective of the period of follow-up. Age and diagnosis at primary total hip replacement were identified as time-dependent predictive factors of failure. During the first 30 days after primary total hip replacement, an age of 80 years or more and hip replacement undertaken as a sequela of trauma, for avascular necrosis or paediatric conditions, were associated with an increased risk of failure. However, during six months to 8.6 years after surgery, being less than 60 years old was associated with an increased risk of failure, whereas none of the diagnoses for primary total hip replacement appeared to be independent predictors

Hip bearing surfaces materials are typically broadly reported in national registry (metal-on-polyethylene, ceramic-on-ceramic etc). We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by detailed types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with detailed head and shell/liner bearing material combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 were included in the primary analysis (Monobloc cups: n=378,979 and Modular cups: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the overall risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the overall risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The overall and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is reduced for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup in reference to THRs with a cobalt chrome head and HCLPE liner/cup

We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared

We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with head and shell/liner combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 are included in the primary analysis (Monobloc: n=378,979 and Modular: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the all-cause risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the all-cause risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The all-cause and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is lower for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup than commonly used alternatives such as cobalt chrome heads and HCLPE liner/cup

Background. Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation. Methods. We used discharge records from the Nationwide Inpatient Sample (2002–2011). Temporal trends were assessed and multivariable logistic regression modeling was used to identify factors associated with dislocation. Results. The in-hospital dislocation rate increased from 0.025% in 2002 to 0.15% in 2011, despite a downward trend in length of stay (P<0.001). Patient characteristics associated with the occurrence of dislocation were black or Hispanic race/ethnicity, lower household income, and Medicaid insurance. Comorbidities associated with dislocation included hemiparesis/hemiplegia, drug use disorder, chronic renal failure, psychosis, and obesity. Dislocations were less likely to occur at teaching hospitals and in the South. Conclusion. The in-hospital dislocation rate following elective primary THA is increasing, in spite of shorter stays and surgical advances over time. Given the sociodemographic disparities in dislocation risk documented herein, interventions to address social determinants of health might do as much or more to reduce the occurrence of dislocation than technical improvements

Objective. To investigate the effectiveness of applying fast track surgery concept in primary total hip arthroplasty. Methods. The data of patients with primary total hip arthroplasty in our department from January 1, 2013 to October 1, 2015 were retrospectively analyzed. The patients were divided into traditional recovery group, enhanced recoverygroup and update enhanced recovery group according to different interventions. The blood loss, transfusion rate, complications rate, postoperative function, length of stay, hospitalization expense and readmission rate were compared between three groups. Results. A total of 435 cases were included. Compared with traditional recovery group, the average blood loss, length of stay and total cases of complication in update enhanced recovery group were reduced 91.44 ml, 1.34 days and 14.05%, respectively, and the differences showed statistical significance. From 2013 to 2015 the hip flexion and abduction degree increased annually, the differences also showed statistical significance. The blood transfusion rate, other complications and hospitalization expense were all reduced, but there were no statistical significance. Conclusions. The emphasis of fast track surgery concept in primary total hip arthroplasty was the management in perioperative period. Through continuous optimization of intervention measures under the guidance of evidence based medicine, it can effectively accelerate recovery, diminish complications and reduce the length of hospital stay

Background. Second-generation high-carbon CoCrMo-alloy metal-on-metal total hip arthroplasty (THA) was introduced in the late 1980s following reports of early loosening, impingement, pronounced wear, and hypersensitivity in the first-generation metal-on-metal articulations. There has been inconsistent data that specifically addresses the clinical performance and longevity of second-generation metal-on-metal THA. The purpose of this study was to evaluate the survival of second-generation metal-on-metal primary THA and to assess the influence of demographic factors on implant survival in a large patient cohort. Methods. One thousand two hundred and seventy second-generation 28 mm metal-on-metal primary THA in 1121 patients were performed at one institution from 1994 to 2004. According to the International Documentation and Evaluation System patients were followed routinely at one year, two years and every five years thereafter. Clinical and radiographic outcome data was prospectively recorded using a hospital joint registry. At a mean follow-up of 6.8 years postoperatively, the probability of survival of THA was estimated using the method of Kaplan and Meier. Relative risk factors for implant failure that included age, gender, BMI, type of implant fixation and size of implant components were calculated using the Cox proportional-hazards model. Results. Sixty three (5%) hips were revised because of aseptic loosening (28 hips), infection (8 hips), periprosthetic fracture (8 hips), recurrent dislocation (8 hips), pain without implant loosening (7 hips) and breakage of the cup (4 hips). The probability of survival at ten years, with revision for any reason as the endpoint, for the THA as a whole was 0.90 (95% confidence interval, 0.87 to 0.94). The probability of survival for the cup was 0.90 (95% confidence interval, 0.86 to 0.93) and for the stem 0.94 (95% confidence interval, 0.91 to 0.97). No demographic factors or covariates were found to significantly affect survivorship. Conclusion. Second-generation metal-on-metal primary THA did not demonstrate a superior probability of survival at ten years compared with previous reports on other weight-bearing surfaces. Based on these findings and with consideration of concerns that relate to putative local and systemic toxicity of metal debris, the use of second-generation metal-on-metal articulations for primary THA remains moot

Objective. The efficacy and safety of tranexamic acid (TXA) on reducing blood loss and transfusion has been confirmed in primary total hip arthroplasty (THA). The main methods of administration includes intravenous, topical alone or combined use, and the most appropriated methods remains undecided. This study was aimed to compare the efficacy and safety of different methods of TXA following primary THA. Methods. We prospectively collected patients' data through National Health Database from January 2013 to December 2016. The patients were divided into control group, intravenous group, topical group and combined group according to the different methods of TXA. The primary outcome was the incidence of transfusion and venous thromboembolism. Secondary outcomes were total blood loss, hemoglobin level on postoperative day 3 and decrease in hemoglobin, incidence of wound complications and other adverse events. Results. A total of 7537 primary THA procedures were collected, 4102 with TXA, 3435 without TXA. 2847 (37.8%) patients received intravenous TXA alone, 235 (3.1%) patients received topical TXA alone and 1020 (13.5%) patients received combined use. The transfusion rate decreased from 33.07% to 12.7% with the use of TXA (p< 0.001). The transfusion rate was 30.21% in topical group, 10.68% in intravenous group, and 14.31% in combined group, with a significant difference between treatment groups (p< 0.01 for all). The hemoglobin on postoperative day 3 in control group was 91.24±17.09 g/L, which was significantly lower than that in topical group (101.38±16.71 g/L), intravenous group (102.79±32.37 g/L) and combined group (104.34±16.67 g/L, p<0.05 for all). The hemoglobin drop on POD 3 in control group was 38.07±18.10 g/L, which was significantly higher than that in topical group (30.02±17.11 g/L), intravenous group (29.35±16.05 g/L) and combined group (29.22±16.37 g/L, p<0.05 for all). The total blood loss in control group was (1377.74 ± 851.97 ml), which was significantly higher than that in topical group (1123.15±628.59 ml), intravenous group (971.08±671.39 ml) and combined group (946.4±724.82 ml, p<0.05 for all). A total of 14 DVT (0.41%) in control group, 4 patients (0.1%) in TXA group occurred DVT, and the difference was significant (0.10%, p= 0.006). Cardiac infarction occurred in 3 patients (0.04%), stroke occurred in 2 patients (0.03%), and 3 patients (0.04%) developed wound infection. No episode of PE or death occurred. Conclusion. TXA was effective and safe to decrease blood loss and transfusion following primary THA no matter of intravenous, topical use alone or combined use. In order to achieve better hemostatic effect, intravenous or combined application was recommended if no contradictions were found

Background. The advent of value-based conscientiousness and rapid-recovery discharge pathways presents surgeons, hospitals, and payers with the challenge of providing the same total hip arthroplasty episode of care in the safest and most economic fashion for the same fee, despite patient differences. Various predictive analytic techniques have been applied to medical risk models, such as sepsis risk scores, but none have been applied or validated to the elective primary total hip arthroplasty (THA) setting for key payment-based metrics. The objective of this study was to develop and validate a predictive machine learning model using preoperative patient demographics for length of stay (LOS) after primary THA as the first step in identifying a patient-specific payment model (PSPM). Methods. Using 229,945 patients undergoing primary THA for osteoarthritis from an administrative database between 2009– 16, we created a naïve Bayesian model to forecast LOS after primary THA using a 3:2 split in which 60% of the available patient data “built” the algorithm and the remaining 40% of patients were used for “testing.” This process was iterated five times for algorithm refinement, and model performance was determined using the area under the receiver operating characteristic curve (AUC), percent accuracy, and positive predictive value. LOS was either grouped as 1–5 days or greater than 5 days. Results. The machine learning model algorithm required age, race, gender, and two comorbidity scores (“risk of illness” and “risk of morbidity”) to demonstrate excellent validity, reliability, and responsiveness with an AUC of 0.87 after five iterations. Hospital stays of greater than 5 days for THA were most associated with increased risk of illness and risk of comorbidity scores during admission compared to 1–5 days of stay. Conclusions. Our machine learning model derived from administrative big data demonstrated excellent validity, reliability, and responsiveness after primary THA while accurately predicting LOS and identifying two comorbidity scores as key value-based metrics. Predictive data has the potential to engender a risk-based PSPM prior to primary THA and other elective orthopaedic procedures

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty. We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis. A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2. nd. postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort. In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted

Purpose. There are still some controversies over the routine use of negative suction drainage after primary total hip arthroplasty (THA). In this study we are to know the benefits of new suction drainage management strategy after primary THA. Materials and methods. From 2010 to 2012, two hundred patients who had unilateral primary THA were randomly allocated into two groups. One group had negative suction drainage immediately after THA (Group 1). In the other group, the suction drainage was inserted but negative pressure was applied more than 12 hours after surgery, in the morning postoperative day one (Group 2). All surgeries were performed by one single hip surgeon using the same technique and postoperative rehabilitation protocol was all same. We checked the amount of blood loss, changes in hemoglobin (Hb), volume of blood transfusion, superficial or deep wound infection and hematoma. Clinical results were evaluated using HHS score. Results. The changes in hemoglobin (Hb) from postoperative 48hrs from immediate THA was not different between two groups (group 1: 0.91±1.10, group 2: 0.77±0.95, p=0.334). However, the changes in Hb postoperative day one from immediate was significantly lower in group 2 (group 1: 4.24±1.09, group 2: 3.61±0.96, p<0.001). The changes in Hb from posteroperative day one and seven were significantly lower in group 2 comparing preoperative Hb (group 1: 1.11±1.52, group 2:0.67±1.57, p=0.043). The amount of total blood drainage was different between two groups (group 1: 437.75±193.51, group 2: 377.25±185.19, p<0.001). The unit number of blood transfusion was also significantly lower in group 2 (group 1: 1.40±1.24, group 2: 0.74±1.03, p <0.001). There was no significant difference about the complication rate between two groups. There was no difference in HHS between two groups. Conclusions. The simple change of negative suction drainage management strategy can reduce the amount of blood loss after primary THA and the volume of blood transfusion

Introduction. In Europe a femoral neck retaining stem (Metha, Aesculap Inc, Tuttlingen, Germany) has been reported with excellent midterm survivorship. We report on a US series and compare it to a review of reports in Europe over the past decade to determine if US experience matches that in Europe. Methods. A review of published studies was performed on PubMed with search terms: Hip, replacement, arthroplasty, and Metha. We found four publications that met the criteria of reporting survivorship and reasons for revision surgery. The results from these four articles combined had 4179 THA with the Metha stem. After IRB approval three orthopaedic groups in the US were used to combine their experience over the last 11 years. These US sources had 824 surgeries performed between 2008–2019. We then reported on all revisions for comparison of survivorship. Results. In the four publications [1–4] there was a reported 4.8% failure over 5–10 years for any reason. In the 824 US cases there were 3 periprosthetic infections, 4 periprosthetic fractures (all within 15 months) and 2 revisions for other reasons (thigh pain and leg length discrepancy). If stem revisions for any reason are taken into account the Kaplan-Meier Survivorship at 5 years is 94.0%, and if only aseptic loosening is considered then the survivorship is 99.1% at 5 years and 98.4% at 11 years. Conclusion. Bone sparing implants for primary total hip replacement have seen the popularization of mid stems in the USA but a FNR stem has not seen significant popularity. This report from a three surgeon experience has excellent survivorship with two aseptic loosening cases both determined at time of periprosthetic fracture. Survivorship for this series at 11 years of 98.4% for aseptic loosening matches many reports of mid length or standard length primary total hip stems in national registry databases

Aims. High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. Methods. A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI. Results. Mean operating time increased with BMI and for BMI > 50 kg/m. 2. was approximately twice that of BMI 10 kg/m. 2. to 15 kg/m. 2. Mean inpatient cost did not vary significantly with BMI. Mean total reimbursement was lowest for the lowest BMI cohort and increased with BMI. Mean LOS was greatest at the extremes of BMI (4.0 days for BMI 10 kg/m. 2. to 15 kg/m. 2. ; 3.75 days for BMI > 50 kg/m. 2. ) and twice that of normal BMI. Mean complication rates were greatest in the lowest BMI cohort (16% for BMI 10 kg/m. 2. to 15 kg/m. 2. ) and five times the mean rate of complications in the normal BMI cohorts. Furthermore, 30-day readmissions were greatest in the highest BMI cohort (10% for BMI > 50 kg/m. 2. ) and five times the rate for normal BMI patients. Conclusion. LOS, complications, and 30-day readmissions all increase at the extremes of BMI and appear to be greater than those of patients with normal BMI. The lowest BMI patients had the lowest payment for inpatient stay yet were at considerable risk for complications and readmission. Patients with extreme BMI should be counselled about their increased risk of complications for THA and nutritional status/obesity optimized preoperatively if possible. Cite this article: Bone Joint J 2020;102-B(7 Supple B):62–70

The purpose of this study is to compare 90-day costs and outcomes for primary total hip arthroplasty (THA) patients between a non-obese (BMI 18.5–24.9) versus overweight (25–29.9), obese (30–34.9), severely-obese (35–39.9), morbidly-obese (40–44.9), and super-obese (45+) cohorts. We conducted a retrospective review of a prospective institutional database of primary THA patients from 2006–2013, including patients with a minimum of three-year follow-up. Thirty-three super-obese patients were identified, and the other five cohorts were randomly selected in a 2:1 ratio (total n = 363). Demographics, 90-day outcomes (costs, reoperations, and readmissions), and outcomes after three years (revisions and change scores for SF12, HHS, and WOMAC) were collected. Costs were determined using unit costs from our institutional administrative data for all in-hospital resource utilization. Comparisons between the non-obese and other groups were made with Kruskal-Wallis tests for non-normal data and chi-square and Fisher's exact test for categorical data. The 90-day costs in the morbidly-obese ($13,134 ± 7,250 mean ± standard deviation, p <0.01) and super-obese ($15,604 ± 6,783, p <0.01) cohorts were statistically significantly greater than the non-obese cohorts ($10,315 ± 1,848). Only the super-obese cohort had statistically greater 90-day reoperation and readmission rates than the non-obese cohort (18.2% vs 0%, p <0.01 and 21.2% vs 4.5%, p=0.02, respectively). In addition, reoperations and septic revisions after 3 years were greater in the super-obese cohort compared to the non-obese cohort 21.2% vs 3.0% (p = 0.01), and 18.2% vs 1.5% (p= 0.01), respectively. There were no other statistical differences between the other cohorts with the non-obese cohort at 90-days or after 3 years. Improvements in SF12, HHS, and WOMAC were comparable in all cohorts. The 90-day costs of a primary total hip arthroplasty for morbidly-obese (BMI 40–44.9) and super-obese (BMI>45) are significantly greater than for non-obese patients, yet these patients have comparable improvements in outcome scores. Health care policies, when based purely on the economic impact of health care delivery, may place morbidly-obese and super-obese patients at risk of losing arthroplasty care, thereby denying them access to the comparable quality of life improvements

Introduction. Although pelvic tilt does not significantly change after primary total hip arthroplasty (THA) at a short term, can vary over time due to aging and the possible appearence of sagittal spine disorders. Cup positioning relative to the stem can be influenced due to these changes. Purpose. We assessed the evolution of pelvic tilt and cup position after THA for a minimum follow-up of five years and the possible appearence of complications. Materials and methods. 47 patients underwent same single THA between 2008 and 2012. All were diagnosed with primary osteoarthritis and their mean age was 70.2 years (range, 63 to 75). There were 28 male patients, 19 had a contralateral THA, 17 were studied for lumbar pathology and three were operated for lumbo-sacral fusion. Radiological analysis included sacro- femoral-pubic and acetabular abduction angles on the anteroposterior pelvic view; and cup anteversion angle on the lateral cross-table hip view according to Woo and Morrey. All assessments were done pre-operatively and at 6 weeks, one, two and five years post-operatively. Three measurements were recorded and mean was obtained at all intervals All radiographs were evaluated by the same author, who was not involved in surgery. Results. There were four dislocations: one early and two contralateral dislocations which were solved wiith closed reduction, and one late recurrent dislocation five years after surgery which required cup revision. No other revision surgeries were performed. Mean sacro-femoral pubic angle decreased at all intervals from 60.6º preoperatively, to 60.0º at one year and 58.8 º at five years. This decrease was more significant in female, 63.3º preoperatively to 59.3º, than in male patients, 58.7º to 58.3º at five years. Mean acetabular abduction angle increased from 47.3º at 6 weeks to 48.2º at five years. Mean cup anteversion increased from 24.3º at 6 weeks to 26.4º at one year and 34.3º at five years. Conclusions. Posterior pelvic tilt increased with aging over time, particularly in women. These changes increased cup inclination and anteversion which may result in more dislocations after primary THA

Introduction. There is growing evidence that patients with lumbar spine fusion are at greater risk for postoperative dislocation following total hip arthroplasty. The purpose of this study is to review one author's experience with the modified direct lateral approach in patients with prior or subsequent lumbar spine fusion and total hip arthroplasty. Methods. Our IRB approved clinical database was queried for all primary total hip arthroplasties performed by the senior author from 1/1/2004 to 12/31/2016. All were performed via a modified direct lateral approach. Of these 1902 hips (1656 patients), 59 were identified in our medical records as patients who had a prior spine fusion or a spine fusion following THA. The extent of fusion was identified and reported. Radiographs were reviewed for acetabular position (abduction and anteversion) and leg length discrepancies. Records were reviewed and patients were contacted to determine if there were dislocations. Results. Of the 59 patients with concomitant spine fusion and total hip arthroplasty, 47 had the fusion prior to THA and 12 following THA. All patients were seen in the office or contacted by phone for a mean follow up of 5.8 years (2 to 15 years)(3 deceased, 3 lost). The direct lateral approach was used in all cases and in no cases was a dual mobility, lipped liner, or constrained component used. Head size ranged from 32 to 40. There were no postoperative dislocations in any of these patients. Acetabular position was a mean 43.6 degrees abduction (range 30–50), and a mean anteversion of 23.7 degrees (range 17 – 34). Average postoperative LLD was 2.8mm long on operated side (range −2mm to + 12mm). Spine fusion extent was a mean 2.1 levels (range 1 – 9) with 15 that included the sacrum/pelvis. Discussion. As surgeons have become aware of the elevated risk of hip dislocation associated with spine fusion/stiffness, several approaches have been proposed to address this risk. Our findings suggest that using the modified direct lateral approach for primary total hip arthroplasty significantly reduces the risk of such a complication. For any tables or figures, please contact the authors directly

The Exeter V40 femoral stem is the most implanted stem in the NJR for primary THA. In 2004, the 44/00/125 stem was released for use in “cement-in-cement” revision cases. It has however been used ‘off-label’ as a primary stem when, for example, patient anatomy requires a smaller stem with a 44mm offset. We aimed to investigate survival of this stem in comparison to others in the range when used in primary THAs recorded in the NJR. Analyses were performed using a dataset based on that used for the 2020 NJR annual report. Our exposure was the stem; the outcome was all-cause construct revision. Crude analyses were performed using Kaplan-Meier and adjusted using Cox models. The 44/00/125 stem was directly compared to other stems in the Exeter range. We analysed 330,732 primary THAs using the Exeter V40 stem comprising 34.5% of the 958,869 THAs with complete information from the start of the NJR to 31 December 2018. The 44/00/125 stem was implanted in 2,158 primary THAs with 67.5% in female patients and a mean age of 67.8. The 10-year revision estimate for the 44/00/125 stem was 4.9% (95%CI 3.6, 6.8) and in constructs using an Exeter V40 stem was 2.8% (95%CI 2.7, 2.8). Controlling for age, sex and ASA demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (HR 1.8 (95%CI 1.4, 2.3)). Although the revision estimate is within the NICE 10-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the Exeter V40 range. Attempts to control for age, sex and ASA will not take into account confounding by indication i.e. patients with more complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured by this but should be aware of the observed increased revision estimate and use the stem according to its indications

Introduction. Total hip arthroplasty (THA) candidates have received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid administration documentation and are now implementing opioid-sparing protocols (OSP) into THA integrated care pathways (ICP). Here we evaluate the effectiveness of a novel OSP in primary THA at out institution. Methods. Between January 2019 to April 2019, all patients undergoing primary THA were placed under a novel OSP (Table 1). Patient demographics, inpatient/surgical factors, and inpatient opiate administration events were collected. A historical 2:1 cohort was subsequently derived from patients undergoing THA between January 2018 to August 2018. Opiate administration events collected from our EDW were converted into Morphine Milligram Equivalences (MMEs) and transformed into average MME's per patient per 24-hour interval. Nursing documented visual analog scale (VAS) pain scores were also queried and averaged per patient per 12-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) Short Forms tool was utilized. Results. 652 primary THAs had received our institution's OSP, and 1357 patients were utilized as our historical control. Age, gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were all similar between the two groups (Table 2). Compared to historical controls, OSP patients demonstrated significantly lower 24-hour interval opiate consumption at 0–24, 24–48 and 48–72 hours. Though VAS pain score variations reached statistical significance at various intervals, differences were not clinically relevant (Table 4). Lastly, OSP patients demonstrated significantly higher AM-PAC scores across all 6 functional domains (Table 5) and raw total scores within 24-hours of surgery completion. Discussion. Our OSP reduced opiate consumption by 26.50% while maintaining a comparable level of self-reported patient pain. Lower opiate utilization may also improve functional status in the immediate postoperative period. For any tables or figures, please contact the authors directly

Antibiotic-impregnated bone cement (ABC) is infrequently used in the North America for primary total hip arthroplasty (THA) due to concerns with cost, performance, and the possible development of antibiotic resistance. The purpose of this study is to examine the cost-effectiveness of using ABC in primary THA for osteoarthritis compared to the use of cement without antibiotics. A Markov decision model was used to determine if ABC is a cost-effective strategy for primary THA in patients with osteoarthritis. The model tabulates costs and quality adjusted life years (QALYs) accumulated by each patient to evaluate the cost-effectiveness of each strategy. Rates of revision for infection and aseptic loosening were estimated from the Norwegian Arthroplasty Register, and were used to determine the probability of transitioning to a revision arthroplasty for either infection or aseptic loosening. The model was also used to evaluate the cost-effectiveness of ABC when only revisions for infection are considered. Peri-operative mortality rates, utilities, and disutilities were estimated from the arthroplasty literature. Costs were also estimated from the literature using in-hospital resource use as the method of measurement for primary THA. The additional cost of using ABC ($600) was then added to the average cost of the initial procedure ($21,654). ABC is less expensive and more effective than standard cement when all revisions are considered, making the use of ABC the dominant strategy. When only revision for infection is considered, the use of ABC has an incremental cost-effectiveness ratio (ICER) of $37.335 per QALY compared to cement without antibiotics – which compares favorably with the cost-effectiveness of accepted medical procedures. Sensitivity analyses reveal that for all revisions the additional cost of ABC would need to be greater than $1500, or the average age of patients undergoing primary THA would need to be greater than eighty-three before the use of ABC would cost more than $50,000 per QALY gained. When only revision for infection is considered, the additional cost of ABC would need to exceed $650 before the cost of ABC would exceed $50,000 per QALY gained. Use of ABC for primary THA is cost-effective over a wide range of assumptions. Notably, when all revisions are considered, ABC is less costly and more effective than use of standard cement over the life span of the patients

Introduction. Dual-mobility (DM) articulations may be useful for patients at increased risk for instability in primary and revision THA. While DM articulations are becoming increasingly popular, its routine use in primary THA is more uncertain. Even less is known about femoral head penetration in DM designs manufactured with highly cross-linked polyethylene infused with Vitamin E (E-HXLPE). The purpose of this study was to evaluate the early clinical results and femoral head penetration rates of primary THA implanted with DM E-HXLPE. Methods. Between 2012 and 2017, 105 primary DM THAs were performed using a one-piece acetabular shell, 28mm ceramic head, coupled with an E-HXLPE outer bearing via a standard posterior approach. Three patients refused follow-up after six months. 102 hips (92 patients) were available for review. The diagnosis was 99% OA. Average age was 65.7 years (33–90 years). 56% of patients were female. The most common femoral head size was 50mm (range, 44–60mm). The average thickness of the E-HXLPE outer bearing was 22.7mm (range, 16–32mm). Patients were followed at two months (baseline radiograph), six months, one, three, five, and seven years. Harris hip scores (HHS), UCLA activity score, and femoral head penetration (Martell method) were obtained at each visit beyond two months. Follow-up averaged 3 years (range, 1–7 years). Results. Average HHS improved from 43 to 95 points (50–100) at final follow-up. Similarly, average Harris pain scores improved from 10 to 42 points (20–44) with 78% of patients pain free and one patient, each, reporting groin and thigh pain (1%). Average UCLA activity scores was 8.1 (range, 5–10). There were no dislocations, revisions, or loose cups. The average femoral head penetration (including bedding-in) was 0.25mm/yr (s.d. 0.2mm/yr) at seven years. Discussion/Conclusion. The theoretical benefits of DM designs in diminishing wear include a smaller inner head, lower frictional torque with motion, less micro-separation, and less wear with impingement. The early clinical results of primary DM THA are promising. Although the early femoral head penetration using DM E-HXLPE appears to be less than other DM designs, it was greater than that of conventional THA using HXLPE and E-HXLPE inserts. The additional outer bearing surface, while affording additional stability, may actually enhance polyethylene creep and wear. For any tables or figures, please contact the authors directly

Dual mobility components for total hip arthroplasty provide for an additional articular surface, with the goals of improving range of motion, jump distance, and overall stability of the prosthetic hip joint. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal head is snap-fit into the large polyethylene. New components have been released for use in North America over the past four years. In some European centers, these components are routinely used for primary total hip arthroplasty. Some surgeons in USA suggest routine use in primary hip arthroplasty. However, their greatest utility is to manage recurrent dislocation in the setting of revision total hip arthroplasty. Recent biomechanical data suggests that, in a 3D CT scan-cadaver hip model, there is no difference in range of motion between a 36mm head and an ADM dual mobility component sizes 50–56mm. There is little wear data on dual mobility components, except from one implant manufacturer. It is feared that there is a “3rd articulation” in dual mobility components—the routine impingement of the femoral neck against the polyethylene femoral head. Several retrospective series have shown satisfactory results for these dual mobility components at short- to medium-term follow-up times. There are important concerns with polyethylene wear, late intra-prosthetic dislocation, and the lack of long-term follow-up data. Big femoral heads (36mm and 40mm) articulating with highly cross-linked, e-beam, remelted, polyethylene are a better choice in primary total hip arthroplasty, to decrease the frequency of dislocation in “high risk” patients. Although the risk of early dislocation was 4% in “high risk” patients, there was no recurrence, no revision, and no late first dislocation. Until further long-term results are available, caution is advised in the routine use of dual mobility components in primary total hip arthroplasty

Aim and Methods. The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs). . Results. There were 564 intra-operative fractures (1.7%); 529 during uncemented stem placement (3.0%) and 35 during cemented stem placement (0.23%). Intra-operative fractures were more common in females and patients over 65 years (p < 0.001). The majority occurred during placement of the femoral component (60%), and involved the calcar (69%). There were 557 post-operative fractures (20-year probability: 3.5%; 95% confidence interval (CI) 3.2 to 3.9); 335 fractures after placement of an uncemented stem (20-year probability: 7.7%; 95% CI 6.2 to 9.1) and 222 after placement of a cemented stem (20-year probability: 2.1%; 95% CI 1.8 to 2.5). The probability of a post-operative fracture within 30 days after an uncemented stem was ten times higher than a cemented stem. The most common post-operative fracture type was a Vancouver A. G . (32%; n = 135), with 67% occurring after a fall. In all, 36% (n = 152) were treated with revision arthroplasty. . Conclusion. In summary, intra-operative fractures occur 14 times more often with uncemented stems. Female patients over 65 years of age are at highest risk. Post-operative fractures are also most common with uncemented stems, but are independent of age or gender. Cumulative risk of post-operative periprosthetic femur fracture was 3.5% at 20 years. Take home message: Intra-operative fractures occur 14 times more often with uncemented stems, particularly with female patients over 65 years of age, while post-operative fracture risk is independent of age or gender, but still increased with uncemented stems. Cite this article: Bone Joint J 2016;98-B:461–7

Introduction. The association between preoperative opioid use and adverse outcomes after total hip arthroplasty (THA) has been reported. However, a quantitative assessment used to evaluate the combined effect of controlled substance use and define a threshold for adverse outcomes after THA has not been established. The current study aimed to identify the association between the NarxCare Score (NCS) (indicative of controlled substance use) and length of stay (LOS), discharge disposition, 90-day emergency department (ED) visits, readmission, and reoperation after primary THA, necessary to identify a preoperative NCS threshold for adverse outcomes. Methods. A total of 2,787 THAs (57.3% female; mean age: 64.3±11.14 years; NCS range: 0–800) were performed between November 2018-January 2020 at an integrated healthcare system with preoperative NCSs. Outcomes assessed included LOS, discharge disposition, 90-day ED visits, readmission (all-cause, procedure and non-procedure-related) and reoperation. The association between NCS category (in 100-point increments) and was analyzed through multivariate logistic regression accounting for risk factors. Results. NCS of zero, 1–99 and 100–199 were similar regarding all investigated outcomes (p>0.05 for all). Compared to a NCS of zero, NCS of 300–399 was independently associated with higher odds of a LOS >2 days (odds ratio [OR]:2.27; 95% confidence interval [CI][1.59–3.24]; p<0.001), non-home discharge (OR: 2.0; 95% CI [1.34–2.99]; p=0.001), 90-day all-cause readmission (OR: 2.0; 95% CI [1.16–3.36]; p=0.012). Furthermore, NCS of 300–399 exhibited higher odds of a procedure-related readmission (OR: 3.74; 95% CI [1.48–8.13]; p=0.004). There were no differences between the NCS strata in 90-day reoperation and non-procedure related readmission rates (p>0.05 for each). Conclusion. Higher NCS was associated with greater LOS and 90-day readmission, as well as lower odds of discharge to home. A NCS threshold of 300 can potentially designate high-risk patients for adverse outcomes after THA. This score may help stratify patients in the current alternative payment environment

Sciatic nerve palsy is a recognised complication of primary total hip replacement. In our unit this complication was rare with an incidence of < 0.2% in the past ten years. We describe six cases of sciatic nerve palsy occurring in 355 consecutive primary total hip replacements (incidence 1.69%). Each of these palsies was caused by post-operative haematoma in the region of the sciatic nerve. Cases, which were recognised early and surgically-evacuated promptly, showed earlier and more complete recovery. Those patients for whom the diagnosis was delayed, and who were therefore managed expectantly, showed little or no recovery. Unexpected pain and significant swelling in the buttock, as well as signs of sciatic nerve irritation, suggest the presence of haematoma in the region of the sciatic nerve. It is, therefore, of prime importance to be vigilant for the features of a sciatic nerve palsy in the early post-operative period as, when recognised and treated early, the injury to the sciatic nerve may be reversed

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group

Introduction. Several surgical approaches are available for elective total hip arthroplasty (THA) for osteoarthritis. While posterior surgical approaches are the most common, interest in a direct anterior (Hueter) approach is increasing because of alleged advantages in convalescence. However, no studies have examined differences in patient-reported global and condition-specific measures of health across multiple institutions. The ongoing Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) study is a PCORI-funded multicenter pragmatic clinical trial randomizing patients to three different antithrombotic regimens. We analyzed operative data from PEPPER to compare pre-post changes in validated patient-reported outcome measures after THA based on surgical approach. Methods. Participants (age 21 or older) were recruited from 27 academic medical centers for the PEPPER trial. Eligibility screening, baseline measures, and operative detail were entered into a central database with standardized blinded post-operative data collection protocol. We included participants undergoing elective primary total hip arthroplasty, excluding those undergoing revision, resurfacing, bilateral procedures, on chronic preoperative anticoagulation, with a recent history of gastrointestinal, cerebral, or other hemorrhage, defective hemostasis, or uncontrolled hypertension. Participating centers reported the operative approach as “Posterior”, “Transgluteal”, or “Anterior”. The brief version of the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS Jr.) and the Patient Reported Outcome Measurement Information System Global Survey (PROMIS10) were ascertained pre-operatively, and at 1, 3 and 6 months post-operatively. Mixed-effects linear regression was used to compare difference in patient-reported outcomes over time based on surgical approach, adjusting for baseline measures of health outcome, patient age, sex, race, ethnicity, BMI, comorbidity, education, work status, alcohol use, and smoking status. Results. As of 5/15/2018, a total of 1,238 patients had undergone primary THA as part of the PEPPER trial and were being monitored postoperatively, including 51.6% involving posterior, 18.1% transgluteal, and 30.3% anterior surgical approaches. Mean preoperative HOOS Jr. scores for posterior approach (47.6; 95%CI 46.4 – 48.7) were similar to transgluteal (47.4, 95%CI 45.4 – 49.5, p=0.654) and anterior (48.9, 95%CI 47.4 – 50.4, p=0.461) approaches. At 6-month follow-up, adjusted mean HOOS Jr. Scores significantly improved for all groups, but were not statistically different between groups. The adjusted mean HOOS Jr. score at 6 months was 85.6 for those undergoing a posterior (95%CI 83.7 – 87.5), 83.6 for transgluteal (95%CI 79.0 – 88.2, p=.474) and 85.0 for anterior approaches (95%CI 82.6 – 87.5, p=0.255). Baseline PROMIS-10 Physical Function scores were similar between posterior (40.1; 95%CI 40.2 – 41.3), transgluteal (40.6, 95%CI 39.6 – 41.6, p=0.716), and anterior approaches (41.5, 95%CI 40.8 – 42.3, p=0.390), with similar postoperative improvement through 6 months (posterior=52.1, 95%CI 51.2 – 53.0; transgluteal=52.4, 95%CI 50.2 – 54.5, p=0.734; anterior=52.8, 95%CI 51.6 – 53.9, p=0.414). These findings were robust utilizing a variety of methods to account for missing responses. Conclusion. We found similar short-term improvements in patient-reported global measures of health between posterior, transgluteal, and anterior surgical approaches for elective THA, and a trend suggesting inferior early patient-reported measures of function with a trans-gluteal surgical approach

The Lubinus SP II is an anatomical femoral stem with high survivorship levels notably described in the Swedish Arthroplasty Register. As the clinical and economic burden of revision total hip arthroplasty (THA) and periprosthetic fracture (PPF) continues to increase, it has been suggested that use of anatomical stems may facilitate more uniform cement mantles and improve implant survival. The primary aim of this study was to determine the long-term survivorship and PPF rate of the Lubinus SP II 150mm stem in a single UK centre. Between January 2007 and April 2012, 1000 consecutive THAs were performed using the Lubinus SP II femoral stem in our institution. Patient demographics and operative details were collected in a prospective arthroplasty database. Patient records and national radiographic archives were then reviewed at a mean of 12.3 years (SD 1.3) following surgery to identify occurrence of subsequent revision surgery, dislocation or periprosthetic fracture. Mean patient age at surgery was 69.3 years (SD 10.1, 24–93 years). There were 634 women (63%). Osteoarthritis was the operative indication in 974 patients (97%). There were 13 revisions in total (4 for recurrent dislocation, 3 for infection, 6 for acetabular loosening) and 16 dislocations (1.6%). Stem survivorship at 10 years was 99.6% (95 % confidence interval [CI], 99.5%–99.7%) and at 15 years was 98.8% (98.7%–98.9%). The 15-year stem survival for aseptic loosening was 100%. Analysis of all cause THA failure demonstrated a survivorship of 99.1% (99.0%–99.3%) at 10 years and 98.2% (98.1%–98.3%) at 15 years. There were 4 periprosthetic fractures in total (0.4%) at mean 12.3 year follow-up. The Lubinus SP II stem demonstrated excellent survivorship, low dislocation rates and negligible PPF rates up to 15 years following primary THA. Use of anatomical stems such as the Lubinus SPII would appear to be a wise clinical and economic investment for patients and healthcare systems alike

Aim: To determine the outcome and need for subsequent surgery in patients following successful closed reduction of dislocation after primary total hip arthroplasty (THA) and the financial implications of re-operation. Methods: Data was retrospectively obtained from radiographs and patient case notes for all dislocated primary hip replacements presenting to the University Hospital of Wales from January 2000 till November 2005. Records were analysed with a minimum of 1 year follow-up to determine the outcome and need for subsequent surgery following successful closed reduction of dislocation after primary THA. Factors studied include age at primary surgery, indications, components, approach, head size, duration since surgery and direction of dislocation. Results: Over the 6 year study period, 98 patients presented with 100 first time dislocated primary total hip replacements. All the dislocations underwent successful closed reduction. 62 (62%) hips re-dislocated more that once. At minimum follow up of 1 year, 7 patients had died and were excluded from the final study group. Of the remaining 93 hips, 46 patients have had no further surgery. 44 THA’s have undergone revision procedures and 3 are waiting to have revision surgery (51% in total). Of those who have undergone revision surgery, 7 hips re-dislocated since and 3 of those needed further re-revision. Discussion: Dislocation following primary THA remains a problem with varying dislocation rates quoted in the literature. In our series, 51% of patients presenting with dislocation required revision surgery. All patients in this series had 28 mm or smaller femoral heads. The financial impact of the burden of revision surgery continues to increase. In this series in isolation the cost of revision surgery totalled greater that £500,000

Early revision is an important risk factor for repeated revision and poor results after primary total hip replacement and instability is a major cause of early revision. Larger articulations with cross-linked polyethylene are proposed as a solution, but these are not without risk, including fracture of the thin polyethylene rim of the liner. The aim of our study was to examine implant-related revisions among primary total hip replacement patients with up to six year follow-up in a randomized controlled trial which compared 28 mm and 36 mm metal on highly cross-linked polyethylene articulations in total hip replacement. 557 patients undergoing primary total hip replacement were included in this study. Risk factors for dislocation and wear were controlled by stratification and patients were then randomized intra-operatively to either a 28 or 36 mm articulation. To date, 10 hips have been revised for implant-related problems following primary total hip replacement. Seven hips with a 28 mm articulation were revised to a larger articulation because of instability. Four of these were for recurrent dislocation, one for an irreduceable first dislocation and two for subluxation. In contrast, only one patient who had undergone total hip replacement with a 36 mm articulation was revised for recurrent dislocation. One hip with a 36 mm articulation in a well-positioned cup was revised to a 32 mm articulation because of elevated lip liner fracture. Another 36 mm articulation hip was revised for acetabular component loosening. This study shows that a 36 mm metal on highly cross-linked polyethylene articulation reduces the need for early revision for instability after primary total hip replacement. However, these benefits need to be weighed against the potential risks associated with these articulations, including rare fracture of the relatively thin poly-ethylene liner

INTRODUCTION. Evolving payment models create new opportunities for assessment of patient care based on total cost over a defined period of time. These models allow for analyses of economic data that was previously unavailable and well beyond our familiar studies which typically include length of stay, surgical complications, and post-operative clinical and radiographic assessments. In the United States, the new Federal program entitled TheBundled Payment for Care Initiative created new opportunities for the assessment of surgical interventions. The purpose of the reported study was to assess the total reimbursement for care as a function of surgical technique in primary total hip arthroplasty (THA). METHODS. The total reimbursement for services performed following primary THA for patients insured by Medicare was analyzed for a group of patients at a single institution during the fiscal years of 2013 and 2014. The population included data on 356 patients who had surgery performed by seven surgeons who used the same pre-operative education, OR, PACU, PT, nursing, and case management. A total of 38 “pre-selected” patients underwent THA by an anterior exposure, 219 had surgery performed by a posterior exposure, and 99 had surgery performed by the superior exposure utilizing mechanical surgical navigation (HipXpert System, Surgical Planning Associates, Boston, MA). Reimbursement for all in-patient and out-patient services performed over the initial 90-day period from sugeical admission was compared across surgical techniques. Reimbursement includes the sum of all payments including the hospital, physicians, skilled nursing facilities, home care, out-patient care, and readmission. RESULTS. The authors previously reported that primary THA cases performed using the superior approach have shorter average length of stay, a lower complication rate, higher percentage of acetabular components within the “safe zone” when compared to the other approaches and higer rate of patients discharged directly to home. An average reimbursement of $24,848 for THA performed using posterior exposure, $21,446 for the selected anterior exposure, and $20,268 for the superior exposure with navigation. The cost of care for treatment by the superior exposure with navigation was statistically significantly less than the posterior exposure (p<0.001) but not significantly less than the selected anterior exposure patients (p=0.287). Medicare in-patient reimbursements for patients treated by the superior exposure with mechanical surgical navigation was significantly less than the selected anterior exposure group (p<0.002) and the posterior exposure group (p<0.001). Overall, 84% of patients with the superior exposure were discharged directly to home versus 69% in the selected anterior group and 60% in the posterior group thus minimizing the out-patient Medicare cost burden in THA performed using the superior exposure over the other techniques. CONCLUSION. The current study demonstrates the influence of surgical technique on the direct reimbursement for the continuum of care, indicative of incurred costs, across the first 90-day post-operative period. The superior exposure combined with surgical navigation demonstrates the potential for significantly reduced total cost burden in Medicare patients when compared to two of the most common surgical approaches used for primary THA

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

Aim. To determine the outcome, the need for revision surgery, quality of life (QOL) of patients and the financial implications of instability following successful closed reduction of dislocation after primary total hip arthroplasty (THA). Methods. Retrospective study. Parameters studied include indications for primary hip replacement, femoral head size, outcome in terms of the rate of recurrent dislocation, time to second dislocation and the need for revision surgery. QOL assessment was made cross-sectionally at a minimum follow-up of 1 year using the Oxford Hip Score (OHS) and the EuroQol-5 Dimension (EQ-5D) questionnaire. Results. Over a 6-year period, 99 patients presented with 101 first time dislocated primary total hip replacements. Mean patient age was 71 years. Head size used was 28mm or smaller in all the hips. All the dislocations underwent successful closed reduction. 61 (60.4%) hips re-dislocated and the median time to the second episode was 103 days. At one-year follow up, 7 patients had died. Of the remaining 94 hips in 92 patients, 48 (51%) THAs have undergone revision procedures. Post-revision, 15% of the hips re-dislocated and more than half of those needed a further surgical procedure to correct the instability. The mean OHS and the EQ-5D health state was observed to get worse with recurrent dislocation and revision surgery and the difference between the mean Oxford hip scores of the revision surgery group and the other 2 groups was statistically significant. The total cost of instability exceeded well over half a million pounds in our series. Discussion. Dislocation following primary THA continues to be a problem and recurrent dislocation presents a significant management challenge. Revision surgery is expensive, has a high failure rate when performed for instability and significantly worsens the QOL of these patients. The financial impact of the burden of revision surgery continues to increase

Introduction: We studied the survival of primary total hip arthroplasty (THA) in patients undergoing surgery because of rheumatoid arthritis (RA) and compared our results to the survival of primary THA in patients undergoing surgery because of osteoarthritis (OA). Furthermore, we evaluated the effect of primary THA-survival in RA-patients concerning multiple confounders such as age, gender, comorbidity, and cemented/uncemented prosthesis. Material and Methods: Using the Danish Hip Arthroplasty Register we gathered info concerning 1.302 primary THA’s in 1.106 RA-patients and 41.848 primary THA’s in 35.729 OA-patients. These patients underwent surgery from 1995 to 2004. Using the Cox regression model we estimated the relative risk (RR) for revision due to aseptic loosening, other reasons, and all reasons and adjusted for above mentioned confounders. Results: The adjusted RR’s for cup-revision of primary THA’s in patients with RA (compared to OA) were 1.22 (aseptic loosening − 95% Confidence Interval (CI) 0.75–1.99), 0.90 (other causes for revision − 95% CI 0.61–1.32), and 1.00 (all revisions − 95% CI 0.74–1.35). For the stem the RR’s were 0.50 (aseptic loosening − 95% CI 0.25–0.99), 0.58 (other causes for revision − 95% CI 0.35–0.95), and 0.54 (all revisions − 95% CI 0.36–0.80). RR for all revisions (both cup and stem) was 0.83 (95% CI 0.64–1.09). The RAsubanalysis showed an increased RR (all revisions) for men compared to women (RR 2.60; 95% CI 1.19–5.66). No significant result concerning all revisions for age, comorbidity, and cemented/ uncemented prosthesis was found. The mean follow-up was 5,4 years for RA and 4,8 years for OA. Conclusion: The survival of primary THA’s in RA could not be associated with any clearly overall increased risk of revision when compared to OA. However, male gender seems to be a risk factor for undergoing revision-THA in the RA-subgroup

Aims. The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana). Patients and Methods. A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture. Results. The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture. Conclusion. Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451–7