Uncertainties in the management of patients with MOM hip implants continue to be a problem for all surgeons. Guidelines vary and do not fully define or quantify thresholds. We aimed to assess the differences in decision-making amongst an international community of six specialist orthopaedic institutions. Five international tertiary referral orthopaedic units (one UK, two USA, and two European) were invited to participate. Each unit organised an MDT panel consisting of 2 or more hip surgeons and a musculoskeletal radiologist. All units discussed the same 10 patients. A full clinical dataset was provided including blood test and all imaging. Differences in the interpretation of findings, management decision and rationale for decisions were compared between institutions.Introduction
Methods
Aims. Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on. Methods. Outcome of hip-preserving head reduction osteotomy combined with periacetabular osteotomy was good in one and moderate in the other up to three years after surgery; based on the pronounced hip destruction, the third received initially a total hip arthroplasty. Results. The described pathology is quite devastating, and extensive joint preserving surgery (which has been shown successful in Perthes’ cases) was less successful in this patient cohort. Conclusion. Supraselective angiography may be helpful to improve pathomechanical understanding and surgical
Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates. A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed. Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria. Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction. These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%. The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate
Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in
Dislocation following revision THA remains a leading cause of failure. Integrity of the abductor muscles is a major contributor to stability. Large diameter heads (LDH), Dual Mobility (DM) and Constrained Acetabular Liners (CAL) are enhanced stability options but the indication for these choices remains unclear. We assessed an algorithm based on Gluteus Medius (GM) deficiency to determine bearing selection. Default choice with no GM damage was a LDH. GM deficiency with posterior muscle intact received DM and CAL for GM complete deficiency with loss of posterior muscle. Consecutive revision THA series followed to determine dislocation, all-cause re-revision and Oxford Hip Score (OHS). 311 revision THA with mean age 70 years (32–95). At a mean follow-up of 4.8 years overall dislocation rate 4.1% (95%CI 2.4–7.0) and survivorship free of re-revision 94.2% (95%CI 96.3–91.0). Outcomes:. Group 1 - LDH (36 & 40mm) n=164 / 4 dislocations / 7 re-revisions. Group 2 - DM n=73 / 3 dislocations / 4 re-revisions. Group 3 - CAL n=58 / 5 dislocations / 7 re-revisions. Group 4 - Other (28 & 32mm) n=16 / 1 dislocation / no re-revisions. Mean pre-op OHS: 19.6 (2–47) and mean post-op OHS: 33.9 (4–48). Kaplan-Meier analysis at 60 months dislocation-free survival was 96.1% (95% CI: 93.0–97.8). There was no difference between survival distributions comparing bearing choice (p=0.46).
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
Sound management decisions are critical to outcomes in revision arthroplasty. Aiming to improve outcomes, revision networks facilitate speciality trained, high volume surgeons, share experience and best practice, contributing to
Although total hip arthroplasty (THA) is beneficial for many patients with hip osteoarthritis (OA), a subset of patients experience minimal benefit. It is therefore pertinent to understand the predictors of poor functional outcome to facilitate shared
Identification of patients at risk of not achieving minimally clinically important differences (MCID) in patient reported outcome measures (PROMs) is important to ensure principled and informed pre-operative
Fixation only of Vancouver B Proximal Femoral Fractures (PFF's), specifically with Cemented Taper Slip stems (CTS) with an intact bone cement interface, has been shown to have reduced blood transfusion requirements and reoperations, compared to revision arthroplasty. This potentially carries the risk of stem subsidence and loosening, which negatively impacts functional outcome. The incidence of stem subsidence and associated fracture morphology have not previously been reported. We retrospectively reviewed all Vancouver B PFF's in primary THR around CTS stems treated with internal fixation only between June 2015 and March 2021 for fracture morphology (Low Spiral (LS), High Spiral (HS), Metaphyseal Split (MS) and Short Oblique (SO)), fracture union and stem subsidence. Interprosthetic fractures and inadequate follow up were excluded. Secondary outcomes were collected. Out of 577 cases on our local periprosthetic database, 134 Vancouver B PFF's around CTS stems were identified, of which 77 patients underwent ORIF only. Of these, 50 procedures were identified, 21 were lost to follow up and 6 patients died before 6 months. Age, mortality rate and ASA is presented. Review of Fracture morphology showed: 100% (3/3) of HS subsided (1 revised for loosening); 68 % (19/28) of MS subsided (1 revised for loosening); 11.1 % (2/18) of LS subsided (0 revised for loosening); 0% (1/1) of SO subsided. There were 2 revisions for non-union (LS group). No dislocations were recorded. There was a statistically significant association between Morphology and Subsidence P value 0.0004). Major subsidence was observed in 8 patients (3 HS, 4 MS and 1 LS) which was associated with a significance reduction in mobility. Subsidence was associated with negative symptoms (P value < 0.0001). Fixation of all Vancouver B PFF's does not produce uniformly good results. Revision rates following ORIF do not fully reflect patient outcomes. This trend will affect the NJR, stem rating and patient satisfaction. Subsidence after ORIF was associated with certain morphologies (HS & MS) and stem revision may be preferrable, in keeping with GIRFT. A morphology-based classification system can inform
Introduction. Patient related outcome measures (PROMS) are now routinely undertaken in patients undergoing hip arthroplasty. These are in the form of the Oxford Hip Score (OHS) and EQ5D questionnaires pre-operation and at 6 months' post operation. MYMOPS is a patient specific outcome measure that allows patients to list their individualised symptoms and activities that are limited and is used is other medical specialities but not currently within orthopaedic surgery. The aim of this study was to validate the MYMOPS questionnaire for use in hip arthroplasty by comparing it to the OHS. Patients/Materials & Methods. At a single centre, 50 patients were recruited to our prospective trial after ethical approval. A MYMOPS questionnaire and an OHS was filled in pre-operation and then at 6 months post-operatively. 6 patients filled in either form incorrectly and were excluded. The remaining 44 included 30 females and 14 males with an average age of 68.5 (range 35–90). Results. There was significant improvement in OHS by an average of 22.8 points post-operatively. There was also a similar significant improvement in all MYMOPS symptoms and activity score and this correlated well with the improvement in OHS. There was no significant difference in improvements between the OHS and MYMOPS with significant correlation demonstrated suggesting that the MYMOPS displays good construct validity compared to the OHS (p<0.05). Discussion. MYMOPS is valid for use in hip arthroplasty patients and shows similar effects as the OHS. It has the added advantage of helping the surgeon see what the main symptoms that patients are suffering from and what activity the patients want to return to and can help identify any unrealistic expectations. In this way, MYMOPS can help shared
Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for
Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for
Aims. A proximal femur fracture (PFF) is a common orthopaedic presentation, with an incidence of over 25,000 cases reported in the Australian and New Zealand Hip Fracture Registry (ANZHFR) in 2018. Hip fractures are known to have high mortality. The purpose of this study was to determine the utility of the Clinical Frailty Scale (CFS) in predicting 30-day and one-year mortality after a PFF in older patients. Methods. A retrospective review of all fragility hip fractures who met the inclusion/exclusion criteria of the ANZHFR between 2017 and 2018 was undertaken at a single large volume tertiary hospital. There were 509 patients included in the study with one-year follow-up obtained in 502 cases. The CFS was applied retrospectively to patients according to their documented pre-morbid function and patients were stratified into five groups according to their frailty score. The groups were compared using t-test, analysis of variance (ANOVA), and the chi-squared test. The discriminative ability of the CFS to predict mortality was then compared with American Society of Anaesthesiologists (ASA) classification and the patient’s chronological age. Results. A total of 38 patients were deceased at 30 days and 135 patients at one year. The 30-day mortality rate increased from 1.3% (CFS 1 to 3; 1/80) to 14.6% (CFS ≥ 7; 22/151), and the one-year mortality increased from 3.8% (CFS 1 to 3; 3/80) to 41.7% (CFS ≥ 7; 63/151). The CFS was demonstrated superior discriminative ability in predicting mortality after PFF (area under the curve (AUC) 0.699; 95% confidence interval (CI) 0.651 to 0.747) when compared with the ASA (AUC 0.634; 95% CI 0.576 to 0.691) and chronological age groups (AUC 0.585; 95% CI 0.523 to 0.648). Conclusion. The CFS demonstrated utility in predicting mortality after PFF fracture. The CFS can be easily performed by non-geriatricians and may help to reduce age related bias influencing surgical
FAI may cause pain or functional impairment for an individual, as well as potentially resulting in arthritis and degeneration of the hip joint. Results from recent randomised control trials demonstrate the superiority of surgery over physiotherapy in patients with FAI. However, there is paucity of evidence regarding which factors influence outcomes for FAI surgery, most notably on patient reported outcomes measures (PROMs). Our study looks to explore factors influencing the outcomes for patients undergoing surgery for FAI utilising data from the Non-Arthroplasty Hip Registry. This study is a retrospective analysis of data collected prospectively via the NAHR database. Patients meeting the inclusion criteria, who underwent surgery between January 2011 and September 2019 were identified and included in the study. Follow-up data was captured in September 2020 to allow a minimum of 12 months follow-up. Patients consenting to data collection received questionnaires to determine EQ-5D Index and iHOT-12 scores preoperatively and at 6 months, 1, 2- and 5-year follow-up. Changes in outcome scores were analysed for all patients and sub-analysis was performed looking at the influence of; FAI morphological subtype, age, and sex, on outcome scores. Our cohort included 4,963 patients who underwent arthroscopic treatment for FAI. There was significant improvement from pre-operative PROMs when compared with those at 6 and 12 months. Pre-operatively, and at 12-month follow-up, iHOT-12 scores were significantly better for the cam / mixed groups compared to the pincer group (p<0.01). In multivariable regression analysis, pincer pathology and a high-grade chondral lesion were associated significantly poorer iHOT-12 improvement at 6 and 12 months (p<0.05). Age (<40 vs >40) demonstrated no statistical significance when considering 12 months outcome scores. This study demonstrates that hip arthroscopy is an effective treatment for patients with symptomatic FAI and shows statistically significant improvements at 12 months. The findings of this study are relevant to orthopaedic surgeons who manage young adults with hip pathology. This will help them to; predict which patients may benefit from operative intervention, and better inform patients, when undertaking shared
Aims. There are many guidelines that help direct the management of
patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken
a study to compare the management of patients with MOM hip arthroplasties in
different countries. . Methods. Six international tertiary referral orthopaedic centres were
invited to participate by organising a multi-disciplinary team (MDT)
meeting, consisting of two or more revision hip arthroplasty surgeons
and a musculoskeletal radiologist. A full clinical dataset including
history, blood tests and imaging for ten patients was sent to each
unit, for discussion and treatment planning. Differences in the
interpretation of findings, management decisions and rationale for
decisions were compared using quantitative and qualitative methods. Results. Overall agreement between the orthopaedic centres and the recommended
treatment plans for the ten patients with MOM hip implants was moderate
(kappa = 0.6). Full agreement was seen in a third of cases, however
split decisions were also seen in a third of cases. Units differed
in their interpretation of the significance of the investigation
findings and put varying emphasis on serial changes, in the presence
of symptoms. Discussion. In conclusion, the management of raised or rising blood metal
ions, cystic pseudotumours and peri-acetabular osteolysis led to
inconsistency in the agreement between centres. Coordinated international
guidance and MDT panel discussions are recommended to improve consensus
in
Aims. A borderline dysplastic hip can behave as either stable or unstable and this makes surgical
Introduction. Recent focus has shifted towards the utilization of deoxyribonucleic acid (DNA) sequencing modalities in periprosthetic joint infection (PJI) diagnosis and organism identification. The purpose of this study was to compare the diagnostic accuracy of next generation sequencing (NGS) to polymerase chain reaction (PCR) multiplex, culture, the Musculoskeletal Infection Society (MSIS) criteria, and the recently proposed criteria by Parvizi et al. [1] in the diagnosis of periprosthetic hip infections. Methods. In this retrospective study, aspirate or tissue samples were collected in 23 revision and 19 primary hip arthroplasties for routine diagnostic workup for PJI and sent to the laboratory for NGS and PCR multiplex. Concordance along with statistical differences between diagnostic studies were calculated using Chi-squared test for categorical data. Results. When comparing to the MSIS criteria, concordance was 71.4% for NGS, 64.3% for PCR, and 92.9% for culture (p<0.001). There was no significant difference based on prior infection (p=0.695), or sample collection method (tissue swab or synovial fluid) (p=0.327). Seven samples were culture positive and NGS negative all of which met both criteria for PJI. Four patients were culture negative but NGS positive, of which 1 (25.0%) met both criteria. Concordance was 100% between the MSIS criteria and criteria proposed by Parvizi et al. [1]. Conclusion. In this initial cohort NGS was more accurate than 16s subunit PCR techniques, but less accurate than culture in the diagnosis of PJI determining the presence or absence of PJI. What is not clear is how NGS will perform against culture in terms of identifying the specific bacterial strain. Currently, laboratory tests used for either criteria for PJI diagnosis should be obtained regardless of NGS along with the overall clinical picture to help guide
Introduction. Analysis of registry data shows that few units achieve results better than 99·98% control limits. Implant selection is considered a predictor of outcome variation in joint replacement. We analysed the outcomes of a unit with statistically “better than expected” results and compared to all other units within the National Joint Registry for England, Wales, Northern Ireland and Isle of Man (NJR). We sought to determine whether improved implant survival following primary total hip replacement (THR) is a centre effect or mediated by implant selection. Methods. We identified 664,761 THRs in the NJR. The exposure was the unit in which the THR was implanted and the outcome all-cause revision. Net failure was estimated using Kaplan-Meier and adjusted analyses used flexible parametric survival analysis. Results. The crude 10-year revision rate for THRs was 1·7% (95% CI: 1·3, 2·3) in the exemplar centre and 2·9% (95% CI: 2·8, 3·0) elsewhere (log rank test P<0·001). Of 6,230 THRs performed in the exemplar centre, 99·9% used the same femoral stem. After restricting analyses to this stem, crude survival from other units was 2·3% (95% CI: 2·2, 2·4) (log-rank test p=0·05). Age and sex adjusted analyses, restricted to the same stem/cup combinations as the exemplar centre, show no demonstrable difference in restricted mean survival time between groups (p=0·28). Conclusion. These results suggest the “better than expected” performance of an exemplar centre can be replicated by adopting key treatment decisions, such as implant selection. These decisions are easier to replicate than technical skills or system factors. This is an important and easily applicable lesson for all branches of medicine highlighting the potential pre-eminence of
Background. Over 10% of total hip arthroplasty (THA) surgeries performed in England and Wales are revision procedures. 1. Malorientation of the acetabular component in THA may contribute to premature failure due to mechanisms such as edge loading and prosthetic impingement. It is known that the pelvis flexes and extends during activities of daily living (ADLs), and excessive pelvic motion can contribute to functional acetabular malorientation. Preoperative radiographs can be performed to measure changes in pelvic tilt during ADLs to identify high risk individuals and inform surgical