Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing. £250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics. 11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort. Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort

The results of total hip arthroplasty (THA) revisions to correct leg length discrepancy (LLD) are not clear, with only two former limited series (< 25 patients). Therefore, we conducted a retrospective study of THA revisions for LLD to determine: 1) the change in LLD, 2) the function outcomes and whether obtaining equal leg lengths influenced function, 3) the complication and survival rates. This multicenter study included 57 patients: 42 THA revisions for limb shortening and 15 revisions for limb lengthening. LLD was measured on conventional radiographs and EOS. The Oxford-12 and FJS outcome scores were collected and the number of patients achieving the Oxford-12 MCID. The revisions were carried out a mean of 2.8 years after the index THA. The median LLD decreased from 7.5 mm (IQR: [5;12]) to 1 mm (IQR: [0.5;2.5]) at follow-up (p=0.0002). Overall, 55 of 57 patients (96%) had < 5 mm LLD at follow-up and 12 patients (21%) had equal leg lengths. The complication rate was 25%: 12 mechanical complications (8 periprosthetic femoral fractures, 2 stem loosening and 1 cup loosening, 1 dislocation) and 1 periprosthetic infection. The patient satisfaction was high with a median FJS of 79.2/100 and 77% of patients reached the Oxford-12 MCID. Lengthening procedures had significantly worst function than shortening (38% vs 91% of patients achieving the Oxford-12 MCID (p=0.0004)). Survivorship was 85% (95% CI: 77.9 – 92.5) at 2 years and 77% (95% CI: 66.3 – 87.1) at 4.6 years when using re-revision for any reason as the endpoint. When LLD after THA does not respond to conservative management, revision THA should be considered. Although revision THA for LLD improved medium-term functional outcomes with a high patient satisfaction rate, especially for shortening procedures, the complication rate was high, particularly related to periprosthetic femoral fracture

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years). Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted

We have reviewed a group of patients with iliopsoas impingement after total hip replacement with radiological evidence of a well-fixed malpositioned or oversized acetabular component. A consecutive series of 29 patients (30 hips) was assessed. All had undergone a trial of conservative management with no improvement in their symptoms. Eight patients (eight hips) preferred continued conservative management (group 1), and 22 hips had either an iliopsoas tenotomy (group 2) or revision of the acetabular component and debridement of the tendon (group 3), based on clinical and radiological findings. Patients were followed clinically for at least two years, and 19 of the 22 patients (86.4%) who had surgery were contacted by phone at a mean of 7.8 years (5 to 9) post-operatively. Conservative management failed in all eight hips. At the final follow-up, operative treatment resulted in relief of pain in 18 of 22 hips (81.8%), with one hip in group 2 and three in group 3 with continuing symptoms. The Harris Hip Score was significantly better in the combined groups 2 and 3 than in group 1. There was a significant rate of complications in group 3. This group initially had better functional scores, but at final follow-up these were no different from those in group 2. Tenotomy of the iliopsoas and revision of the acetabular component are both successful surgical options. Iliopsoas tenotomy provided the same functional results as revision of the acetabular component and avoided the risks of the latter procedure

In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this and this pandemic has tested their adaptability. This study is aimed at assessing the impact of covid-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures. This retrospective multi-centre cohort study compared all patients admitted with hip fractures, between 1. st. March and 30th May 2019 (Group PC: Pre-Covid) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: Covid). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality. 580 patients were included (304 PC, 276 C). Patient Charlson comorbidity index and Nottingham Hip Fracture scores were broadly similar across the two cohorts. There was a significant reduction in percentage of total hip replacements in Group C (11% to 5%, p=0.006). There was an increase in conservative management in group C (1% to 5%, p=0.002). The time to theatre was significantly delayed in Group C (43.7 hours C versus 34.6 hours PC, p<0.001). Overall length of hospital stay was similar in both groups (16.6 days PC versus 15 days C, p=0.089). 30-day mortality rate in Group C was 9.8% compared to 8.2% in Group PC (p=0.431), but for covid (+) patients it was significantly higher at 38.2% versus 5.8% in covid (−) patients (p<0.001). This is one of the largest multi-centre comparative cohort study in the literature to date, examining the impact of the covid-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, covid patients were almost seven times more likely to die, reflecting the seriousness of the covid-19 infection and its sequelae in such elderly, vulnerable patients

Greater trochanteric pain syndrome is a painful condition characterised by pain around the greater trochanter usually affecting middle-aged women. The majority of patients will improve with conservative management such as physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs); however, if this fails then more invasive treatments including corticosteroids and surgery may be required. Platelet-rich plasma (PRP) is an autologous blood product, which has a higher concentration of growth factors postulated to provide enhanced healing and anti-inflammatory properties. The Hip Injections PRP Vs Placebo (HIPPO) trial aims to assess the ability of ultrasound-guided PRP injections to improve symptoms and function in patients with GTPS. 64 patients were enrolled and randomised to either the PRP or placebo (normal saline) treatment arm. Two patients decided to drop out of the trial. Clinical outcomes in both groups were evaluated and compared using the International Hip Outcome Tool-12 (iHOT12), Visual Analogue Scale (VAS) of pain, the modified Harris Hip Score (mHHS) and the presence or absence of complications at 3 and six months. The level of significance was set at p<0.05. Both groups received physiotherapy after the injections. The mean age was 57.5. There were 6 males and 56 females with M:F ratio of 1:9.3. Both groups were similar in terms of demography and preoperative scores. The iHOT12 score improved from 28.23 to 45.42 at three-months and decreased slightly to 42.44 at six-months in the Placebo group. The iHOT12 in the PRP group improved from 35.51 to 44.47 at three-months and decreased to 39.78 at six-months. Both groups showed improved VAS and mHHS at three-months compared to the baseline with no statistically significant difference between the two groups (p >0.05). The scores decreased at six-months however remained above the baseline. No complications were reported. Gender and age had no effect on outcomes. Both groups similarly improved from baseline. Physiotherapy can be considered as an important factor in patients' treatment. Further research should be conducted to investigate the role of physiotherapy in the treatment of GTPS

Research into the treatment of Femoro-Acetabular Impingement (FAI) has focussed on surgical correction of structural abnormalities and tended to overlook the dynamic process of impingement. The role of Physiotherapy in addressing abnormal hip movement and any resulting effect on the symptoms of FAI remains untested. A pilot study was therefore instigated to evaluate the effect of physiotherapy on pain and function in patients with FAI. 30 adults aged between 18 and 50 years with a diagnosis of symptomatic FAI were recruited. 23 (77%) completed the study. Intervention was 3 months of specialist physiotherapy focused on improving pelvic and proximal femoral control. The control group received routine care. All functional outcomes improved in the Physiotherapy group and this included improvement beyond minimal clinically important difference and measurement error on the Hip Outcome Score. There was marginal improvement in pain in both groups. Results suggest that physiotherapy treatment can improve function in adults with symptomatic FAI. Larger studies are needed to evaluate the role of conservative management in FAI

Aims

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

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Introduction. Hip and groin injuries are common in athletes participating in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion injuries involving tendons attaching to the symphysis pubis have previously been described and can be managed both operatively and non-operatively. The aim is to describe a rare variant of this injury; complete avulsion of the adductor sleeve complex including adductor longus, pectineus and rectus abdominus. A surgical technique is then outlined which promotes a full return to pre-injury level of sporting activity. Patients/Materials & Methods. Fifteen high level athletes with an MRI confirmed acute adductor complex avulsion injury (6–34 days) were identified from the institution's sports injury database over a 10 year period. All underwent surgical repair. The operative procedure comprised anatomical attachment of the avulsed tissues in all cases (plus mesh reinforcement of the inguinal wall in 7 patients). All underwent a standard format of rehabilitation which was then individualised to be sport specific. Results. One patient developed a superficial wound infection which was successfully treated with antibiotics. 12 out of 15 patients complained of transient local numbness which resolved in all cases. All patients (including 7 elite athletes) returned to their previous level of participation in sport. Discussion. Injury to the triad of adductor longus, pectineus and rectus abdominus should be considered in athletes presenting with groin pain following forced adduction. All athletes underwent early surgical exploration, previous studies have shown prolonged symptoms in early conservative management. Adductor tenotomy has shown previously acceptable results but may be less suitable in elite athletes with higher functional demands when operative repair has been shown to be successful. Conclusion. Operative repair of acute sleeve avulsion of the adductor complex in high level athletes, followed by sport specific rehabilitation promotes return to previous level of participation in sport

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Aims

The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks.

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

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.

Aims

The aim of this study was to evaluate the long-term clinical and radiographic outcomes of the Birmingham Interlocking Pelvic Osteotomy (BIPO).

Aims

The aim of this study was to examine the real time in vivo kinematics of the hip in patients with cam-type femoroacetabular impingement (FAI).

Objectives

Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible.

The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws.

Objectives

The spinopelvic relationship (including pelvic incidence) has been shown to influence pelvic orientation, but its potential association with femoroacetabular impingement has not been thoroughly explored. The purpose of this study was to prove the hypothesis that decreasing pelvic incidence is associated with increased risk of cam morphology.

Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity.

Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific.

One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport.

Cite this article: Bone Joint J 2015;97-B:1488–92.