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). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people. Cite this article: Bone Jt Open 2023;4(10):766–775

Pre-operative definitive diagnosis of infection in painful total hip arthroplasty (THA) is not always easy to be established, making the intra-operative decision-making process crucial in management of revision hip surgery. Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJIs. From November 2020 to December 2022, 105 patients with painful primary THA were treated with revision THA in 3 orthopaedic departments. Pre-operatively, 23 were considered infected and treated with two-stage revision THA. The remaining 82 were likely infected according to the 2019 EBJIS criteria. The suspicion of low-grade infection was based on clinical (rest and/or night pain), laboratory (CRP, ESR, WBC – normal or slightly elevated) and radiological evaluation (loosening). Hip aspiration under CT imaging was performed in these cases and 34 of them yielded positive culture and were treated with two-stage revision. Aspiration was ineffective in the remaining 48 cases (33 negative, 15 unsuccessful attempts). Intra-operatively, calprotectin was measured with lateral flow immunoassay test in these patients. Cases with calprotectin levels ≥ 50 mg/L were treated with 2-stage revision THA; otherwise, they were considered not-infected and one-stage revision was performed. Synovial fluid and tissue samples were collected for analysis. Implants were sent for sonication fluid cultures. Calprotectin was positive (≥ 50 mg/L) in 27 cases and negative in 21 cases. There was 1 false negative case with positive tissue cultures. Out of the 27 positive cases, 25 had positive tissue cultures and sonication. However, 2 cases with high calprotectin levels (>200 mg/L) were not infected. The false positive result was attributed to severe metallosis. Calprotectin sensitivity was 96.2%, specificity 90.9%, PPV 92.6%, NPV 95.2%, AUC 0.935. The results of this ongoing study indicate that calprotectin seems to be a valuable tool in facilitating the intra-operative decision-making process in cases that low-grade infection is suspected and diagnosis cannot be established pre-operatively

Aims. To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. Methods. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). Results. The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Conclusion. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making. Cite this article: Bone Jt Open 2023;4(3):168–181

Aims. The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS). Methods. Data from 686 patients (882 hips) with hip dysplasia who underwent transposition osteotomy of the acetabulum, a type of PAO, between 1998 and 2019 were reviewed. After screening the study included 442 patients (582 hips; response rate, 78%). Patients who completed a study questionnaire consisting of the visual analogue scale (VAS) for pain and satisfaction, FJS-12, and Hip disability and Osteoarthritis Outcome Score (HOOS) were included. The ceiling effects, internal consistency, convergent validity, and PASS thresholds of FJS-12 were investigated. Results. The median follow-up was 12 years (interquartile range 7 to 16). The ceiling effect of FJS-12 was 7.2%, the lowest of all the measures examined. FJS-12 correlated with all HOOS subscales (ρ = 0.72 to 0.77, p < 0.001) and pain and satisfaction-VAS (ρ = -0.63 and 0.56, p < 0.001), suggesting good convergent validity. Cronbach’s α was 0.95 for the FJS-12, which indicated excellent internal consistency. The median FJS-12 score for preoperative Tönnis grade 0 hips (60 points) was higher than that for grade 1 (51 points) or 2 (46 points). When PASS was defined as pain-VAS < 21 and satisfaction-VAS ≥ 77, the FJS-12 threshold that maximized the sensitivity and specificity for detecting PASS was 50 points (area under the curve (AUC) = 0.85). Conclusion. Our results suggest that FJS-12 is a valid and reliable assessment tool for patients undergoing PAO, and the threshold of 50 points may be useful to determine patient satisfaction following PAO in clinical settings. Further investigation of the factors influencing postoperative joint awareness may enable improved prediction of treatment efficacy and informed decision-making regarding the indication of PAO. Cite this article: Bone Joint J 2023;105-B(7):760–767

Aims. While cementless fixation offers potential advantages over cemented fixation, such as a shorter operating time, concerns linger over its higher cost and increased risk of periprosthetic fractures. If the risk of fracture can be forecasted, it would aid the shared decision-making process related to cementless stems. Our study aimed to develop and validate predictive models of periprosthetic femoral fracture (PPFF) necessitating revision and reoperation after elective total hip arthroplasty (THA). Methods. We included 154,519 primary elective THAs from the Swedish Arthroplasty Register (SAR), encompassing 21 patient-, surgical-, and implant-specific features, for model derivation and validation in predicting 30-day, 60-day, 90-day, and one-year revision and reoperation due to PPFF. Model performance was tested using the area under the curve (AUC), and feature importance was identified in the best-performing algorithm. Results. The Lasso regression excelled in predicting 30-day revisions (area under the receiver operating characteristic curve (AUC) = 0.85), while the Gradient Boosting Machine (GBM) model outperformed other models by a slight margin for all remaining endpoints (AUC range: 0.79 to 0.86). Predictive factors for revision and reoperation were identified, with patient features such as increasing age, higher American Society of Anesthesiologists grade (> III), and World Health Organization obesity classes II to III associated with elevated risks. A preoperative diagnosis of idiopathic necrosis increased revision risk. Concerning implant design, factors such as cementless femoral fixation, reverse-hybrid fixation, hip resurfacing, and small (< 35 mm) or large (> 52 mm) femoral heads increased both revision and reoperation risks. Conclusion. This is the first study to develop machine-learning models to forecast the risk of PPFF necessitating secondary surgery. Future studies are required to externally validate our algorithm and assess its applicability in clinical practice. Cite this article: Bone Joint Res 2025;14(1):46–57

Aims. Social media is a popular resource for patients seeking medical information and sharing experiences. periacetabular osteotomy (PAO) is the gold-standard treatment for symptomatic acetabular dysplasia with good long-term outcomes. However, little is known regarding the perceived outcomes of PAO on social media. The aims of this study were to describe the perceived outcomes following PAO using three social media platforms: Facebook, Instagram, and X (formerly known as Twitter). Methods. Facebook, Instagram, and X posts were retrospectively collected from 1 February 2023. Facebook posts were collected from the two most populated interest groups: “periacetabular osteotomy” and “PAO Australia.” Instagram and X posts were queried using the most popular hashtags: #PAOwarrior, #periacetabularosteotomy, #periacetabularosteotomyrecovery, #PAOsurgery, and #PAOrecovery. Posts were assessed for demographic data (sex, race, location), perspective (patient, physician, professional organization, industry), timing (preoperative vs postoperative), and perceived outcome (positive, negative, neutral). Results. A total of 1,054 Facebook posts, 1,003 Instagram posts, and 502 X posts were consecutively assessed from 887 unique authors. The majority (63.3%) of these posts were from patients in the postoperative period, with a median of 84 days postoperatively (interquartile range 20 to 275). The longest follow-up timeframe postoperatively was 20 years. Regarding perceived outcomes, 52.8% expressed satisfaction, 39.7% held neutral opinions, and 7.5% were dissatisfied. Most dissatisfied patients (50.9%) reported pain (chronic or uncontrolled acute) as an attributing factor. Conclusion. Most PAO-perceived surgical outcomes on social media had a positive tone. Findings also indicate that a small percentage of patients reported negative perceived outcomes. However, dissatisfaction with PAO primarily stemmed from postoperative pain. Social media posts from other sources (physicians, hospitals, professional organizations, etc.) trend towards neutrality. Healthcare providers must consider the social media narratives of patients following PAO, as they may reveal additional outcome expectations and help improve patient-centred care, create informed decision-making, and optimize treatment outcomes. Cite this article: Bone Jt Open 2024;5(1):53–59

Aims. Hip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels. Methods. We undertook a systematic review and meta-analysis of observational studies of older (> 60 years) people with fragility hip fractures and outcomes with and without SARS-CoV-2 infection during the first wave of the COVID-19 pandemic. The primary outcome was early (30-day or in-hospital) mortality. Secondary outcomes included length of hospital stay and key clinical characteristics known to be associated with outcomes after hip fracture. Results. A total of 14 cohort and five case series studies were included (692 SARS-CoV-2 positive, 2,585 SARS-CoV-2 negative). SARS-CoV-2 infection was associated with an overall risk ratio (RR) for early mortality of 4.42 (95% confidence interval (CI) 3.42 to 5.82). Early mortality was 34% (95% CI 30% to 38%) and 9% (95% CI 8% to 10%) in the infected and noninfected groups respectively. Length of stay was increased in SARS-CoV-2 infected patients (mean difference (MD) 5.2 days (3.2 to 7.2)). Age (MD 1.6 years (0.3 to 2.9)); female sex (RR 0.83 (95% CI 0.65 to 1.05)); admission from home (RR 0.51 (95% CI 0.26 to 1.00)); presence of dementia (RR 1.13 (95% CI 0.94 to 1.43)); and intracapsular fracture (RR 0.89 (95% CI 0.71 to 1.11)) were not associated with SARS-CoV-2 infection. There were statistically, but not clinically, significantly greater Nottingham Hip Fracture Scores in infected compared with non-infected patients (MD 0.7 (0.4 to 0.9)). Conclusion. SARS-CoV-2 infection is associated with worse outcomes after hip fracture. This is not explained by differences in patient characteristics. These data can be used to support informed decision-making and may help track the impact of widespread adoption of system-level and therapeutic changes in management of the COVID-19 pandemic. Cite this article: Bone Jt Open 2021;2(5):314–322

Aims. Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. Methods. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Results. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. Conclusion. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two ‘at risk’ alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making. Cite this article: Bone Jt Open 2023;4(3):182–187

Dislocation is still one of the more common reasons for revision of THR.Registry and large institutional data has demonstrated the effectiveness of Dual Mobility articulations in reducing revision for dislocation after THR. There is little data about whether the use of dual mobility is associated with a comprised clinical functional outcome. This study aimed to ascertain whether the use of Dual Mobility articulations (DM cups) comes within a compromise to the functional of the THR procedure as measured by the Hip disability and Osteoarthritis Outcome Score (HOOS). Utilising a retrospective design, patients were grouped into those with DM cups with 12 PROMs (Cohort 1) or a large data base of all THR procedures also with a complete set of 12 month PROMs (Cohort 2). The 2 groups were matched for age and gender through propensity score matching. The comparison focused on five domains of the HOOS: Pain, Symptoms, Activities of Daily Living (ADL), Sports and Recreation, and Quality of Life (QOL) at 6- and 12-months post-operation. 12 month PROM data suggested a convergence in scores for several domains, no uniform superiority of one articulation type over the other was found across all domains. These results suggest that both DM cup and standard articulations can effectively improve patient-reported outcomes in THR surgeries, but there are variations in recovery within each cohort that are potentially influenced by factors beyond the articulation type. This study contributes to the ongoing dialogue on optimising prosthetic selection to enhance recovery trajectories and quality of life for THR patients, emphasising the critical role of evidence-based decision-making in orthopaedic surgery

Aims. The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. Methods. The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds. Results. The expert group achieved strong consensus in 32 out of 36 factors following the Delphi process. The RHCC used the existing Paprosky (acetabulum and femur), Unified Classification System, and American Society of Anesthesiologists (ASA) classification systems. Patients with ASA grade III/IV are recognized with a qualifier of an asterisk added to the final classification. The classification has good intraobserver and interobserver reliability with Kappa values of 0.88 to 0.92 and 0.77 to 0.85, respectively. Conclusion. The RHCC has been developed through a modified Delphi technique. RHCC will provide a framework to allow discussion of complex cases as part of a local or regional hip revision MDT. We believe that adoption of the RHCC will provide a comprehensive and reproducible method to describe each patient’s case with regard to surgical complexity, in addition to medical comorbidities that may influence their management. Cite this article: Bone Jt Open 2022;3(5):423–431

OpenPredictor, a machine learning-enabled clinical decision aid, has been developed to manage backlogs in elective surgeries. It aims to optimise the use of high volume, low complexity surgical pathways by accurately stratifying patient risk, thereby facilitating the allocation of patients to the most suitable surgical sites. The tool augments elective surgical pathways by providing automated secondary opinions for perioperative risk assessments, enhancing decision-making. Its primary application is in elective sites utilising lighter pre-assessment methods, identifying patients with minimal complication risks and those high-risk individuals who may benefit from early pre-assessment. The Phase 1 clinical evaluation of OpenPredictor entailed a prospective analysis of 156 patient records from elective hip and knee joint replacement surgeries. Using a polynomial logistic regression model, patients were categorised into high, moderate, and low-risk groups. This categorisation incorporated data from various sources, including patient demographics, co-morbidities, blood tests, and overall health status. In identifying patients at risk of postoperative complications, OpenPredictor demonstrated parity with consultant-led preoperative assessments. It accurately flagged 70% of patients who later experienced complications as moderate or high risk. The tool's efficiency in risk prediction was evidenced by its balanced accuracy (75.6%), sensitivity (70% with a 95% confidence interval of 62.05% to 76.91%), and a high negative predictive value (96.7%). OpenPredictor presents a scalable and consistent solution for managing elective surgery pathways, comparable in performance to secondary consultant opinions. Its integration into pre-assessment workflows assists in efficient patient categorisation, reduces late surgery cancellations, and optimises resource allocation. The Phase 1 evaluation of OpenPredictor underscores its potential for broader clinical application and highlights the need for ongoing data refinement and system integration to enhance its performance

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 decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients. This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures. Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8. This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options

The Paprosky acetabular bone defect classification system and related algorithms for acetabular reconstruction cannot properly guide cementless acetabular reconstruction in the presence of porous metal augments. We aimed to introduce a rim, points, and column (RPC)-oriented cementless acetabular reconstruction algorithm and its clinical and radiographic outcomes. A total of 123 patients (128 hips) were enrolled. A minimum 5-year radiographic follow-up was available for 96 (75.8%) hips. The mean clinical and radiographic follow-up durations were 6.8±0.9 (range: 5.2–9.2) and 6.3±1.9 (range: 5.0–9.2) years, respectively. Harris hip score (HHS) improved significantly from 35.39±9.91 preoperatively to 85.98±12.81 postoperatively (P<0.001). Among the fixation modes, 42 (32.8%) hips were reconstructed with rim fixation, 42 (32.8%) with three-point fixation without point reconstruction, 40 (31.3%) with three-point fixation combined with point reconstruction, and 4 (3.1%) with three-point fixation combined with pelvic distraction. Complementary medial wall reconstruction was performed in 20 (15.6%) patients. All acetabular components were radiographically stable. Nine-year cumulative Kaplan–Meier survival rates for 123 patients with the endpoint defined as periprosthetic joint infection, any reoperation, and dissatisfaction were 96.91% (confidence interval [CI]: 86.26%, 99.34%), 97.66% (CI: 92.91%, 99.24%), and 96.06% (CI: 86.4%, 98.89%), respectively. Cup stability in cementless acetabular reconstruction depends on rim or three-point fixation. The continuity of the anterior and posterior columns determines whether the points provide adequate stability to the cup. Medial wall reconstruction is an important complementary fixation method for rim or three-point fixation. The patients who underwent cementless acetabular reconstruction guided by the RPC decision-making algorithm demonstrated satisfactory mid-term clinical function, satisfaction levels, radiographic results, and complication rates

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 decision making. One such predictor is preoperative radiographic OA severity. The aim of this systematic review was to determine whether preoperative radiographic OA severity could predict postoperative patient-reported outcome measures (PROMs) and satisfaction rates after THA. This systematic review was conducted according to PRISMA guidelines, and the protocol published in PROSPERO (ID:Â CRD42023445918). A literature search was performed using Embase, MEDLINE and Cochrane Library databases. Demographics, radiographic OA severity, PROMs, satisfaction, and complications after THA were collected. A meta-analysis was performed, where appropriate, using a random-effects model. Of 631 identified articles, 12 were included in the final analysis (8,034 participants; mean age 65.2, 38.1% male, mean BMI 29.1 kg/m2). There were three key findings. Firstly, those with mild OA are less likely to achieve a meaningful clinical improvement in PROMs (odds ratio (OR) 0.50, 95% confidence interval (CI) 0.38, 0.65; p < 0.00001). Secondly, two studies indicates that postoperative patient satisfaction was lower in participants with mild OA. Thirdly, participants with mild arthritis experience less improvement in SF-36 physical functioning (mean difference (MD) -8.31, 95% CI -10.97, -5.64; p < 0.00001) and role physical (MD -5.59, 95% CI -8.40, -2.77; p < 0.0001), but showed higher improvement in general health (MD 1.68, 95% CI 0.31, 3.06; p = 0.02). Patients with mild OA, as determined radiographically, are less likely to achieve meaningful clinical improvements in PROMs and have lower postoperative satisfaction after THA. This information will improve collaborative decision-making in the preoperative period

Hip dysplasia is a common cause of hip pain in young adults. Pelvic osteotomy (PO) techniques are the gold standard for treating symptomatic patients, albeit technically demanding. This study aimed to (1) evaluate the 90-day complication rate, and (2) investigate the reasons, frequency and timing of reoperations following primary PO procedures. We retrospectively analysed the National Hospital Episode Statistics database, examining all patients aged over 14 who underwent PO in NHS England hospitals from 2010 to 2023. We identified index procedures and reoperations using relevant OPCS-4 codes. We analysed patient demographics, 90-day complications, and readmission rates for ipsilateral metalwork removal, revision PO, hip arthroscopy (HA), and THR conversion, and calculated the mean time to reoperations. This study included 1,348 PO cases (mean age: 28.7±9.1 years, 89.5% female). The mean hospital stay was 5.4±3.9 days, with a 90-day readmission rate of 0.52% at a mean of 51.0±17.2 days. The most common causes were infection (0.22%) and reoperation (0.15%). The 90-day rate of pulmonary embolism and deep vein thrombosis was 0.074%. One patient died within 90 days. Overall, 810 patients (60.1%) were readmitted for a subsequent hip procedure at a mean of 2.12±1.90 years following their primary PO. Metalwork removal was required in 616 patients (45.7%) at a mean of 1.70±1.19 years. Readmission rates for revision PO, HA, and THR, were 4.23% (mean time: 2.89±0.82 years), 4.15% (mean time: 2.91±2.28 years) and 6.01% (mean time: 5.24±3.08 years) respectively. This study highlights a low 90-day complication rate following primary PO, but a high reoperation rate, mainly for metalwork removal. We provide the most up-to-date report of revision PO, HA and THR conversion rates in England. These findings provide valuable insight that can facilitate informed decision-making, expectation-setting, and post-operative planning, also establishing a benchmark for future quality improvement

The 2020 London International Hamstring Consensus meeting was convened to improve our understanding and treatment of hamstring injuries. The multidisciplinary consensus panel included 14 International specialists on the management of hamstring injuries. The Delphi consensus process consisted of two rounds of surveys which were completed by 19 surgeons from a total of 106 participants. Consensus on individual statements was regarded as over 70% agreement between panel members. The consensus group agreed that the indications for operative intervention included the following: gapping at the zone of injury (86.9%); high functional demands of the patient (86.7%); symptomatic displaced bony avulsions (74.7%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (71.4%). Panel members agreed that surgical intervention had the capacity to restore anatomy and function, while reducing the risk of injury recurrence (86.7%). The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help to further standardise the treatment of hamstring injuries and facilitate decision-making in the surgical treatment of these injuries

Aims. One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. Methods. In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. Results. Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years’ time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. Conclusion. Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678–1685

Aims. To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. Methods. We included 53,099 patients with cemented THA due to osteoarthritis from the Swedish Hip Arthroplasty Registry for model derivation and internal validation, as well as 125,428 patients from England and Wales recorded in the National Joint Register for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey (NJR) for external model validation. A model was developed using a bootstrap ranking procedure with a least absolute shrinkage and selection operator (LASSO) logistic regression model combined with piecewise linear regression. Discriminative ability was evaluated by the area under the receiver operating characteristic curve (AUC). Calibration belt plots were used to assess model calibration. Results. A main effects model combining age, sex, American Society for Anesthesiologists (ASA) class, the presence of cancer, diseases of the central nervous system, kidney disease, and diagnosed obesity had good discrimination, both internally (AUC = 0.78, 95% confidence interval (CI) 0.75 to 0.81) and externally (AUC = 0.75, 95% CI 0.73 to 0.76). This model was superior to traditional models based on the Charlson (AUC = 0.66, 95% CI 0.62 to 0.70) and Elixhauser (AUC = 0.64, 95% CI 0.59 to 0.68) comorbidity indices. The model was well calibrated for predicted probabilities up to 5%. Conclusion. We developed a parsimonious model that may facilitate individualized risk assessment prior to one of the most common surgical interventions. We have published a web calculator to aid clinical decision-making. Cite this article: Bone Joint J 2021;103-B(3):469–478

Aims. To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications. Methods. The study cohort consisted of THAs recorded in the National Joint Registry between 2003 and 2015, linked to national mortality data. First revision THAs for PFF, infection, dislocation, and aseptic loosening were identified. We used a flexible parametric model to estimate the cumulative incidence function of death at 90 days, one year, and five years following first revision THA and primary THA, in the presence of further revision as a competing risk. Analysis covariates were age, sex, and American Society of Anesthesiologists (ASA) grade. Results. A total of 675,078 primary and 74,223 first revision THAs were included (of which 6,131 were performed for PFF). Following revision for PFF, mortality ranged from 9% at 90 days, 21% at one year, and 60% at five years in the highest risk group (males, ≥ 75 years, ASA ≥ 3) to 0.6%, 1.4%, and 5.5%, respectively, for the lowest risk group (females, < 75 years, ASA ≤ 2). Mortality was greater in all groups following first revision THA for PFF than for primary THA. Compared to mortality risk after first revision THA for infection, dislocation, or aseptic loosening, revision for PFF was associated with higher five-year mortality in all groups except males < 75 years with an ASA ≤ 2. Conclusion. Mortality risk after revision THA for PFF is high, reaching 60% at five years in the highest risk patient group. In comparison to other common indications for revision, PFF demonstrated the highest overall risk of mortality at five years. These estimates can be used in the surgical decision-making process and when counselling patients and carers regarding surgical risk. Cite this article: Bone Joint J 2020;102-B(12):1670–1674

The purpose of this study is to understand the lived experience of mature patients who undergo a periacetabular osteotomy (PAO), a major surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to better understand how the PAO impacted the lives of the patients and their families, with a long-term goal of improving the experience. We utilized a phenomenological approach with in-depth, semi-structured interviews to investigate the experience of seven women, ages 25–40, who underwent a PAO. A modified intensity sampling method coupled with criterion sampling was used. Inclusion criteria included raising at least one child and being in a committed relationship with a partner. Analysis of interview transcripts revealed eight themes, each of which falls into one of three chronological periods. From the start of dysplasia symptoms until meeting the PAO surgeon: (1) frustration with symptoms disrupting daily activities, (2) discouragement from misdiagnoses and lack of explanation for symptoms, and (3) fear of the PAO operation. During the PAO decision-making process: (1) the importance of education regarding the PAO procedure and full understanding of its purpose, and (2) the utility of social media to learn from past PAO patients in order to feel more confident about the decision to undergo PAO. Post-operation through recovery: (1) feelings of helplessness, isolation and difficulty asking for help, (2) relying heavily on family and/or close friends for assistance, and (3) desire for more support and communication from the healthcare team. Our findings suggest that the psychosocial burden of PAO surgery is great, with major impact on the patient and family. Many important issues lie outside the scope of what healthcare teams currently address