Aims. The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years. Methods. This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs). Results. A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83). Conclusion. In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127–133

Aims. The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients. Methods. We undertook a longitudinal cohort study linking the Swedish Hip Arthroplasty Register with the National Patient Register, including patients with a neurological disease presenting with a femoral neck fracture and treated with HA, a conventional THA (cTHA) with femoral head size of ≤ 32 mm, or a dual-mobility component THA (DMC-THA) between 2005 and 2014. The dislocation rate at one- and three-year revision, reoperation, and mortality rates were recorded. Cox multivariate regression models were fitted to calculate adjusted hazard ratios (HRs). Results. A total of 9,638 patients with a neurological disease who also underwent unilateral arthroplasty for a femoral neck fracture were included in the study. The one-year dislocation rate was 3.7% after HA, 8.8% after cTHA < 32 mm), 5.9% after cTHA (= 32 mm), and 2.7% after DMC-THA. A higher risk of dislocation was associated with cTHA (< 32 mm) compared with HA (HR 1.90 (95% confidence interval (CI) 1.26 to 2.86); p = 0.002). There was no difference in the risk of dislocation with DMC-THA (HR 0.68 (95% CI 0.26 to 1.84); p = 0.451) or cTHA (= 32 mm) (HR 1.54 (95% CI 0.94 to 2.51); p = 0.083). There were no differences in the rate of reoperation and revision-free survival between the different types of prosthesis and sizes of femoral head. Conclusion. Patients with a neurological disease who sustain a femoral neck fracture have similar rates of dislocation after undergoing HA or DMC-THA. Most patients with a neurological disease are not eligible for THA and should thus undergo HA, whereas those eligible for THA could benefit from a DMC-THA. Cite this article: Bone Joint J 2022;104-B(1):134–141

Cheilectomy is a recommended procedure for early stage osteoarthritis of the 1st metatarsophalangeal joint. Although improvement in symptoms has been reported in many studies, long term performance is not well understood. It is thought that significant numbers of patients require subsequent arthrodesis or arthroplasty. We report on a large cohort of patients receiving this procedure and on complications, and mid-term outcome.

This is a retrospective study looking at all patients undergoing cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to record outcome measures including: postoperative wound infection, patient reported improvement in pain and incidence of further surgical interventions like revision cheilectomy, conversion to arthrodesis and arthroplasty. Osteoarthritis was staged radiographically using PACS (Hattrup and Johnson classification).

A total of 240 feet in 220 patients (20 bilateral surgeries) were included with 164 females (75%) and 56 males (25%), the median age being 55 years (range 22–90 years). Radiological assessment showed 89 stage 1 arthritis (42%), 105 stage 2 (50%), 17 stage 3 (8%) and 9 patients were excluded due to unavailable radiographs. 5 patients (2%) had superficial wound infections. There were 16 further surgeries (7%); 12 arthrodesis (5%), 3 revision cheilectomy and 1 conversion to arthroplasty. 157 patients were found to be pain-free at the latest post-operative visit (77%), 48 reported minimal pain (23%), 15 patients were excluded due to incomplete data.

Cheilectomy appears to effectively reduce pain with low complication rates. Rates of conversion to arthrodesis/arthroplasty are lower than in many reported studies.

Several bisphosphonates are now available for the treatment of osteoporosis. Porous hydroxyapatite/collagen (HA/Col) composite is an osteoconductive bone substitute which is resorbed by osteoclasts. The effects of the bisphosphonate alendronate on the formation of bone in porous HA/Col and its resorption by osteoclasts were evaluated using a rabbit model. Porous HA/Col cylinders measuring 6 mm in diameter and 8 mm in length, with a pore size of 100 μm to 500 μm and 95% porosity, were inserted into a defect produced in the lateral femoral condyles of 72 rabbits. The rabbits were divided into four groups based on the protocol of alendronate administration: the control group did not receive any alendronate, the pre group had alendronate treatment for three weeks prior to the implantation of the HA/Col, the post group had alendronate treatment following implantation until euthanasia, and the pre+post group had continuous alendronate treatment from three weeks prior to surgery until euthanasia. All rabbits were injected intravenously with either saline or alendronate (7.5 μg/kg) once a week. Each group had 18 rabbits, six in each group being killed at three, six and 12 weeks post-operatively. Alendronate administration suppressed the resorption of the implants. Additionally, the mineral densities of newly formed bone in the alendronate-treated groups were lower than those in the control group at 12 weeks post-operatively. Interestingly, the number of osteoclasts attached to the implant correlated with the extent of bone formation at three weeks. In conclusion, the systemic administration of alendronate in our rabbit model at a dose-for-weight equivalent to the clinical dose used in the treatment of osteoporosis in Japan affected the mineral density and remodelling of bone tissue in implanted porous HA/Col composites

Background. An increasing number of hip prostheses are inserted without bone cement. Experimental research has shown that hydroxyapatite (HA) coated implants are strongly fixated in the bone, which is believed to reduce the likelihood of prosthetic loosening. However, in recent years, there has been much debate about the role of HA particles in third-body polyethylene (PE) wear and formerly we have shown the revision rate to be high among older-design HA coated cups. Purpose. We hypothesized increased PE wear-rate using HA coated acetabular components in comparison with non-HA coated components (control group). Materials and Methods. We performed a retrospective comparative clinical study based on two patient populations identified in the Danish Hip Arthroplasty Registry (October 2006). All patients had primary total hip arthroplasty (THA) between 1997 and 2001 with cementless Mallory-Head acetabular components. One group received HA coated acetabular components (75 patients, 77 hips). The other group received identical components without HA (70 patients, 73 hips). In all cases the liner was similar and 28 mm metal femoral heads were used. All patients were invited for a radiographic follow-up in 2007. The AP radiographs were analysed for two-dimensional (2D) polyethylene wear using the semi-automated PolyWare software. All cases of non-responders, stem revisions, hip dislocations and patients with less than 5 years of follow-up were excluded from the analysis. Findings/Results. The 2D linear PE wear-rate of 0.18 mm/year (SD 0.09) was higher (P<0.001) in the group with HA coated cups (n = 54) compared with 0.12 mm/year (SD 0.07) in the group of non-HA coated cups (n = 35). The Effect size of the difference in linear PE wear-rate, established as Cohen's d, was large (0.9). The time of follow-up was similar (p = 0.11) in the HA group (7.2 years) versus the non-HA group (7.6 years). There was no case-mix concerning distribution of gender and operated side in the groups; however, the mean age was lower (P = 0.001) in the HA group (57 years) compared with the non-HA group (63 years). Conclusions. We found a significantly increased PE wear rate in HA coated acetabular components at midterm follow-up. The patients with HA coated cups were younger on average, and this might partly explain the findings because the activity level expectedly is higher in younger patients. Still an effect size of 0.9 is large and should raise concern and supplement considerations in future clinical decisions on component selection. A randomized (RSA) study on newer type crosslinked polyethylene liners is recommended to bring about more information on the clinical performance and longevity of HA coated acetabular components

Introduction. Displaced femoral neck fractures in elderly are normally treated with 2 screws/pins (IF) or bipolar hemiarthroplasty (HA). The aim of this study was to compare IF and HA as treatment for displaced femoral neck fractures using reoperations and functional result (patient satisfaction, pain, and quality of life) as outcome. Material and Methods. From January 2005 all hip fractures in Norway are reported to the Norwegian Hip Fracture Register. At 4, 12, and 36 months postoperatively a questionnaire assessing satisfaction (VAS 0-100), pain (VAS 0-100), and quality of life (EQ-5D) is sent to the patients. To ensure more than 3 years follow-up, only patients operated in 2005 were included in the present study. Consequently 1,968 patients over 70 years of age operated with IF (n = 958) or HA (n = 1,010) due to displaced femoral neck fractures were included in the analyses on reoperations. Of these, 280 patients responded to all questionnaires and were included in the analyses on functional results (IF: n = 135, HA: n = 145). The patients remained in the same treatment group according to the intention-to-treat principle. Results. Through December 2008 496 (51.8%) patients had died in the IF group and 519 patients (51.4%) in the HA group. There were 238 (24.8%) reoperations performed in the IF group and 26 (2.6%) in the HA group. For the 280 patients included in the analyses on functional results, no preoperative differences were found between the two treatment groups concerning sex, comorbidity (ASA-class), cognitive dysfunction, and EQ-5Dindexscore. However, the patients in the HA group were older than the patients in the IF group (79.7 vs 77.7 years, p = 0.002). At all follow-ups, the HA-group were significant more satisfied with the result of the operation compared to the IF-group. The HA group reported less pain compared to the IF group after four months (18 vs 35, p<0.001) and after twelve months (16 vs 29, p<0.001). After 3 years no difference in pain between the two groups could be found. After four months the EQ 5Dindexscore was 0.69 in the HA-group and 0.58 in the IF-group (p<0.001), after twelve months 0.75 in the HA-group and 0.67 in the IF-group (p = 0.001), and after 3 years follow-up 0.74 in the HA-group and 0.71 in the IF-group (p<0.089). Discussion and Conclusion. There were more reoperations in the IF group than in the HA group. The superior functional results found in the HA group after 4 and 12 months were less evident after 3 years. For this frail patient group, a short rehabilitation period with minimized need for reoperations is important, and consequently, a hemiarthroplasty should be recommended as treatment for displaced femoral neck fractures

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Aims

This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA.

Background. A well conducted randomised study found similar functional results for patients with displaced femoral neck fracture comparing operation with a modern uncemented bipolar hemiarthroplasty with a cemented bipolar hemiarthroplasty. The mortality associated with the two procedures has not been sufficiently investigated. Aim of study. To investigate the mortality and the risk factors for death among patients with displaced femoral neck fractures the first year after surgery, comparing operation with modern uncemented and cemented bipolar hemiarthroplasty (HA). Methods. 8,636 patients (65 years and older) with displaced femoral neck fractures (Garden 3 and 4) operated with a cemented (n = 6,907) or a uncemented bipolar HA (n = 1,729) were selected from the files of The Norwegian Hip Fracture Register 2005–2009. Mortality was assessed using Kaplan-Meier survival analysis and risk factors of death were investigated using Cox-regression analysis. A power analysis showed the study sample to be sufficient to detect a difference in mortality of 3% at one year postoperatively. Results. Overall mortality one year postoperatively was 27%. We found no difference in the risk of death when comparing operation with cemented with uncemented bipolar HA one year (RR = 0.97, p = 0.51), 240 days (RR = 1.00, p = 0.95), 120 days (RR = 1.04, p = 0.57), and 30 days (RR = 1.12, p = 0.23) postoperatively. However, 10 days postoperatively there was an increased risk of death for patients operated with cemented HA compared to those operated with uncemented bipolar HA (RR = 1.34, p = 0.03). High age, male gender, cognitive impairment, increasing ASA score, and delay in surgery >48 hours after injury were all associated with an increased risk of death one year postoperatively. Interpretation. The early increased risk of death for patients operated with a cemented HA might be caused by the bone cement implantation syndrome. Our results further indicate that the difference in mortality one year postoperatively is likely to be less than 3%

Background/Aims. The development of extendable prostheses has permitted limb salvage surgery in paediatric patients with bone tumours in proximity to the physis. Prostheses are extended to offset limb length discrepancy as the child grows. Aseptic loosening (AL) is a recognised complication. The implant stem must fit the narrow paediatric medullary canal and remain fixed while withstanding growth and increasing physical demands. Novel designs incorporate a hydroxyapatite (HA) coated collar that manufacturers claim improves bony ongrowth and stability, providing even stress distribution in stem and shoulder regions and providing a bone-implant seal, resulting in decreased AL and prolonged survival. This study aims to assess whether there is a relationship between bony ongrowth onto a HA collar and AL. Hypothesis: Bone ongrowth onto the HA collar of extendable prostheses is associated with more stable fixation and less AL despite patient growth. Methods. Retrospective review of 51 primary partial femoral extendable prostheses implanted over 12 years from 1994–2006 (followed up to death at a mean of 2.5±2.2 years or last clinical encounter at a mean of 8.6 years) and 24 subsequent revisions, to ascertain failure rate and mode, together with a cohort study reviewing bony ongrowth onto the HA coated collar in 10 loose and 13 well fixed partial femoral, humeral and tibial implants. Patient growth was measured as a change in bone:implant-width ratio. Results. 21 (41.2%) primary femoral implants failed at a mean 42.8 months, 5 through AL. 1 secondary implant was revised for AL. 2 implants displayed evidence of progressive AL but had not failed at last follow-up. 5 of 11 tibial component revisions in distal femoral replacement were due to AL. 1 major complication occurred after revision surgery for AL in a primary implant: deep infection requiring 2 stage revision. Bony collar ongrowth was significantly higher in all 4 quadrants (anterior, posterior, medial and lateral) in the well-fixed as opposed to loose group, demonstrating a strong negative relationship in each quadrant between bony ongrowth and AL (p0.001) in the presence of patient growth as shown by increased bone:implant width ratio. In both groups, collar ongrowth was greatest in the posterior quadrant. Summary and Conclusions: AL has been confirmed as a common cause of failure in massive extendable endoprostheses. Revision surgery is difficult and may cause serious complications. For the first time, a significant relationship between a well fixed implant stem and bony ongrowth onto a HA coated collar in the context of massive implants used in tumour surgery has been demonstrated. This newly-proven relationship may result in longer-term implant survival and thus a reduced need for revision surgery. It is hoped that this study will provide the basis for further study of this relationship

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Background. Systematic reviews disagree, but some recent studies have shown better function and less pain after operation with bipolar hemiarthroplasty compared to fixation by two screws in elderly patients operated for displaced femoral neck fractures. There is still uncertainty regarding the mortality associated with both procedures. Aim of the study. To investigate mortality and the risk factors for death among patients with displaced femoral neck fractures within the first three years after surgery, comparing operation with bipolar hemiarthroplasty (HA) and internal fixation (IF) by two screws. Methods. 12,313 patients (65 years or older) with displaced femoral neck fractures (Garden 3 and 4) operated either with IF by two screws (n = 3,436) or a bipolar HA (n = 8,877) were selected from the files of The Norwegian Hip Fracture Register 2005–2009. Mortality was assessed using Kaplan-Meier survival analysis and risk factors for death were studied using Cox-regression analysis. A power analysis showed the study sample to be sufficient to detect a difference in mortality of 3% at one and three years postoperatively. Results. The overall one-year mortality was 28% and three-year mortality was 50%. High age, male gender, cognitive impairment, increasing ASA score and delay in surgery >48 hours after injury were all associated with increased risk of death. For patients operated with a bipolar HA there was a statistically significant increased risk of death at day 30 (RR = 1.30, p<0.01), day 120 (RR = 1.15, p = 0.01), and day 240 (RR = 1.10, p<0.01) postoperatively compared to IF by two screws. At one year (RR = 1.04, p = 0.28) and three years (RR = 1.05, p = 0.16) postoperatively, we found no difference in the risk of death when comparing operation with bipolar HA to IF by two screws. Interpretation. The mortality for patients with displaced femoral neck fractures was considerable and dependent on age, gender, ASA score, cognitive status, and timing of surgery. Given the small magnitude of the difference in short-term mortality and no difference in one- and three-year mortality (or at least less than 3%) between the two treatment groups, we do not believe our findings should influence the choice of treatment method

Aims

Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Aims

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

Aims. Will Hydroxyapatite hip (HA) arthroplasty associated with ceramic bearings produce uncomplicated function in younger, active patients’ The incidence of aseptic loosening, dislocation and broken implants has been particularly investigated. Debris disease from plastic debris contributes to aseptic loosening. Hard-Hard bearings should obviate this problem. Metal-metal will release ions which might be deleterious. Experience with metal-metal resurfacing has high lighted problems including pseudo-tumours. Ceramic bearings may fracture but otherwise appear free of complications. Methods. This is a study extending over 19 years of 626 HA hip arthroplasties with ceramic bearings. Annual review using Harris Hip Score to assess pain and function and X-rays to check osseointegration has been performed. Alumina ceramic was inserted in 467 hips. The newer Zirconia Toughened Alumina (ZTA) has been inserted in 169 hips. There are 118 hips still under review at 10 or more years. Results. Aseptic loosening is unusual (one stem, two acetabulae (3 of 1252 components, 0.24%) Failure from mal-orientation with repeated dislocation occurred in six hips (0.96%). Three alumina heads (0.48%) and two alumina liners (0.32%) broke. There has been no failure of ZTA ceramic. No patients have thigh pain. Osteolysis and debris disease have not arisen. Harris Hip Scores show 91.2% scoring over 90 or 100. Lower scores mostly relate to other joint and medical problems. Conclusions. Assessments confirm that patients remain well. Aseptic loosening of HA hips is rare at 0.24%. Failure from broken alumina components is unusual. Alumina has now been superseded by ZTA for implantation. Ceramic on ceramic is a reliable selection for bearing surfaces in patients of any age and either sex

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (sd 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation.

Cite this article: Bone Joint J 2013;95-B:1538–43.

This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (sd 4.4), 12.9 weeks (sd 6.2) and 12.3 weeks (sd 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups.

This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications.

Aims

This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review.