The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient reported outcome measures (PROMs) of the Olympia stem. Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. PROMs were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score and patient satisfaction at mean 10-years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3 to 17.8) following THA to identify occurrence of complications or revision surgery for any cause. Mean patient age at surgery was 68.0 years (SD 10.9, 31–93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). Stem survivorship at 10 years was 99.2% (95 % confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%–100%). The 15-year stem survival for aseptic loosening was 100%. Only one occurrence of peri-prosthetic fracture was identified, with no episodes of dislocation found. At a mean of 10 (SD 0.8, 8.7 –11.3) years follow-up, mean OHS was 39 (SD 10.3, range 7 – 48) and 94% of patients reported being very satisfied or satisfied. The Olympia stem demonstrated excellent 10-year PROMs, very high rates of stem survivorship and negligible peri-prosthetic fracture and dislocation rate at final follow-up beyond 15 years

Aims. Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. Methods. This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. Results. Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75. th. percentile) proportion of recent surgical admission compared to a low (25. th. percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). Conclusion. A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264–270

Aims. Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. Methods. The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group. Conclusion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72–78

High tibial osteotomy (HTO) is a common procedure for treating medial compartment knee arthritis. The main goal is to reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral compartment and thus delaying the need of total knee replacement (TKR) by slowing or stopping destruction of medial compartment. Between 2002 and 2010, 34 HTO's were carried out in 32 patients (Mean age 44.2). Results were reviewed in 23 patients with an average follow-up of 10.2 years (range 6–14 years). Oxford knee score (OKS) assessment was carried out on those patients. Of the remaining 11 patients, one was excluded, 2 were lost to follow-up, and 2 had died. Five cases had TKR at an average 8.8 years since having HTO. OKS results revealed nine cases (39.1percnt;) scored (40–48) which indicate satisfactory joint function and don't require treatment. Three cases (13percnt;) scored (30–39) indicating mild to moderate arthritis. Six cases (26.1percnt;), scored (20–29) indicating moderate to severe arthritis. Five cases (21.8percnt;) scored (0–19) indicating severe arthritis. Only five patients (14.7percnt;) had TKR (6–14) years after there HTO. The majority of cases had an OKS suggesting satisfactory joint function. Even those with scores suggesting moderate to severe arthritis were able to function normally for more than 6 years. The successful outcome of HTO can be maintained for more than 6–16 years. We conclude that HTO should be recommended for the treatment of medial compartment arthritis of the knee in young and active patients for symptomatic improvement and maintenance of activity levels

Introduction. In contrast to knee arthroplasty, there is no national register on high tibial osteotomy (HTO) in Sweden. The knowledge of the outcome of HTO as a treatment alternative for knee osteoarthritis (OA) is insufficient. The rate of revision to knee arthroplasty after HTO at 10 years has been reported to vary between 8 and 49%. The aim of the study was to evaluate the outcome of HTO performed in Sweden 1998–2007, expressed by rate of revision to knee arthroplasty. Patienter och Material: 3 196 HTO (69% men) 30 years or older operated on for knee OA in Sweden 1998–2007 were identified through the in- and out-patient care registers from the Swedish National Board of Health and Welfare. Side, left/right, that was operated, diagnosis and indication for surgery were verified through surgical records. Conversions of HTO to knee arthroplasty before 2010 were identified through the Swedish Knee Arthroplasty Register (SKAR). In about 10% of the cases it was unknown what side the HTO had been performed on and thus if the arthroplasty had been on the same knee. In these cases we assumed a worst case scenario of all having been on the same side as the HTO. A 10-year survival analysis was performed using revision to an arthroplasty as the end point. Result. The mean age was 52 years (range 30- 80) with 97% of the patients younger than 65 years. The cumulative revision rate (CRR) at 10 year was 29.4% (95% CI 27.2–32.9) after adjusting for age and gender. The risk of revision increased by increasing age and the risk of revision after adjusting for age was significantly higher in women than men RR 1.30 (95% CI 1.11–4.54). Most of the HTO's were performed by open wedge osteotomy using external fixation. The risk of revision was higher for closed wedge osteotomies when comparing the closed and open wedge methods RR1.29 (95% CI 1.08–1.55). Conclusion. 70% of the high tibial osteotomies performed in Sweden 1998–2007 had not been converted to a knee replacement, using the 10 year cumulative revision rate. If it is considering beneficial to have no implant in the knee, high tibial osteotomy may be considered as an alternative to TKA in the younger and physically active patients

Introduction. High Tibial Osteotomy has become an increasingly popular management option for patients with painful medial compartment osteoarthritis. The Fujisawa method used to calculate the angle of correction is well-documented but there have been no studies to look at the reliability and accuracy of web-based systems to calculate this angle. Patients and Methods. Patients undergoing valgus high tibial osteotomy between October 2004 and February 2010 who had full-length lower-limb views on the Picture Archiving and Communications System (PACS). The Fujisawa angle and length of osteotomy were calculated by the surgeon and two Orthopaedic registrars who had been appropriately trained. Results. Thirty X-rays were reviewed in 28 patients. Mean difference between measurements was 0.43 mm (SD 2.45) There was a statistically significant correlation between all three raters (P < 0.001). The greatest correlation was between the Consultant and the more senior trainee (r=0.86) with the lowest correlation between the Consultant and the more junior trainee (r=0.70). Concordance correlation coefficient between raters varied from 0.81 to 0.63. Bland-Altman plot of agreement between the Consultant and senior trainee was excellent showing only two values lying outside 1.96 SD. Discussion. Comparison of measurements between raters showed increased accuracy with greater experience of the measurement technique. Despite this we show high correlation between raters with measurement accuracy of all raters found within clinically acceptable limits (< 1mm). Conclusion. Measurement of tibial osteotomy using the fujisawa method on a web-based X-ray interpretation system is accurate and reliable

Aims. Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function. Patients and Methods. All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between 2009 and 2014 were identified. Fracture classification and operative information including weight-bearing status, rates of union, re-operation, failure of implants and mortality rate, were recorded. Results. A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of the cases, (67%) with the remainder performed under direct consultant supervision. In total 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%), 17 (15%) and 25 (22%), respectively. Conclusion. Our study suggests an exponential increase in the incidence of a fracture of the distal femur with age, analogous to the population suffering from a proximal femoral fracture. Allowing immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was not associated with failure of fixation. There was a high rate of union and low rate of re-operation. Cite this article: Bone Joint J 2017;99-B:951–7

SIGN guidelines advise the use of flucloxacillin and gentamicin instead of cefuroxime as antibiotic prophylaxis for elective hip and knee arthroplasty. It is our impression that this change in practice has been associated with an increased risk of acute kidney injury (AKI). During a twelve month period we examined the incidence of AKI sequentially in four groups of patients: cefuroxime prophylaxis (n = 46); high dose flucloxacillin (5-8g) with single shot gentamicin (n = 50); low dose flucloxacillin (1-4 g) with single shot gentamicin (n = 45); and finally cefuroxime again (n = 52). There were no statistically significant differences by chi-square tests for age, gender, operation (hip or knee), ASA, anaesthesia, baseline serum creatinine, hypertension, diabetes or pre-operative medication. The proportion of patients in each antibiotic group with any form of AKI by RIFLE criteria was: cefuroxime group 1 (9%), high dose flucloxacillin (52%), low dose flucloxacillin (22%), cefuroxime 2 (14%) (p < 0.0001 by chi-square test). Odds ratios (OR) for AKI derived from a multivariate logistic regression model and assigning an OR of 1 to cefuroxime group 1 was: high dose flucloxacillin 14.5 (95% CI, 4.2, 50.2); low dose flucloxacillin 3.0 (0.8-10.9) and cefuroxime group 2 1.9 (0.5, 7.4). Three patients in the high dose flucloxacillin group required temporary haemodialysis. We have shown a strong association between high dose prophylactic flucloxacillin and subsequent development of AKI. We have no reason to believe that this was confounded by any of the co-variates we measured

The primary aim was to assess survival of the opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early (before 12 years) conversion to total knee arthroplasty (TKA). During the 18-year period (1994–2011) 111 opening wedge HTO were performed at the study centre. Mean patient age was 45 years (range 18–68) and the majority were male (84%). Mean follow-up was 12 (range 6–21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed. Forty (36%) HTO failed at a mean follow-up of 6.3 (range 1–15) years. The five-year survival rate was 84% (95% confidence interval (CI) 82.6–85.4), 10-year rate 65% (95% CI 63.5–66.5) and 15-year rate 55% (95% CI 53.3–56.7). Cox regression analysis identified older age (p<0.001) and female gender (hazard ratio (HR) 2.37, 95% CI 1.06–5.33, p=0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62–0.81, p<0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26–4.91, p=0.01) risk of failure in patients aged 47 years old or more. The risk of early conversion to TKA after an opening wedge HTO is significantly increased in female patients and those older than 47 years old. These risk factors should be considered pre-operatively and discussed with patients when planning surgical intervention for isolated medial compartment osteoarthritis

Objective. High grade hallux rigidus is a forefoot deformity characterized by a limitation of dorsiflexion of the first toe associated with pain, and severe damage of the first metatarsophalangeal joint. Most authors recommended resection arthroplasty or arthrodesis of the first metatarsophalangeal joint. The aim of this study was to present the results of our series of 42 consecutive cases of severe hallux rigidus treated by resection of the first metatarsal head and implant of a poly D-L lactic (PDLLA) bioreabsorbable spacer to promote the interposition of fibrous tissue to preserve the range of motion of the joint. Material and methods. Forty-two feet in 27 patients affected by high grade hallux rigidus were included in the study. Surgical treatment consisted of resection of the first metatarsal head and positioning of a poly D-L lactic acid (PDLLA) bioreabsorbable implant. Post-operative care consisted in gauze bandage of the forefoot, and immediate weight-bearing with talus shoes for 3 weeks. All patients were clinically and radiographically evaluated preoperatively and checked at a mean 6 (5–7) year follow-up. Results. No intraoperative complication occurred. No sinus formation were observed. All implants resulted well tolerated by the patients. Mean AOFAS score was 42±14 preoperatively and 81±9 postoperatively. Mean preoperative metatarsophalangeal joint ROM was 27±17 degrees and mean postoperative metatarsophalangeal joint ROM was 75±8 degrees. Conclusions. First metatarsophalangeal joint arthroplasty using bioreabsorbable implant demonstrated to be an effective surgical option for treatment of high grade hallux rigidus, thank to its ability to promote fibrous tissue formation during its reabsorption

We aimed to analyse complication rates following medial opening-wedge high tibial osteotomy (OWHTO) for knee OA. A regional retrospective cohort study of all patients who underwent HTO for isolated medial compartment knee OA from 2003–2013. 115 OWHTO were performed. Mean age = 47 (95%CI 46–48). Mean BMI = 29.1 (95%CI 28.1–30.1). Implants used: 72% (n=83) Tomofix, 21% (n=24) Puddu plate, 7% (n=8) Orthofix Grafts used: 30% (n=35) autologous, 35% (n=40) artificial and 35% (n=40) no graft. 25% (n=29) of patients suffered 36 complications. Complications included minor wound infection 9.6%, major wound infection 3.5%, metalwork irritation necessitating plate removal 7%, non-union requiring revision 4.3%, vascular injury 1.7%, compartment syndrome 0.9%, and other minor complications 4%. Apparent higher rates of non-union occurred with the Puddu plate (8.3%) relative to Tomofix (3.6%) but was not statistically significant. No other significant differences existed in complication rates relative to implant type, bone graft used, patient age or BMI. Serious complications following HTO appear rare. The Tomofix has an apparent lower rate of non-union compared to older implants but greater numbers are required to determine significance. There is no significant difference in union rate relative to whether autologous graft, artificial graft or no graft is used

Background. Medial opening-wedge high tibial osteotomy is one of the common surgical procedures in treatment of knee deformities. Many methods have been proposed to fill the medial side osseous gap. The results of using allograft as void filler compared to iliac crest autograft has not been subject to a randomized clinical trial. The purpose of this study was to examine the results of medial opening-wedge high tibial osteotomy using iliac crest allograft as compared to iliac crest autograft. Materials & Methods. Forty-six patients with genovarum deformity were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. Medial opening-wedge high tibial osteotomy was done using iliac crest allograft (23 patients) or autograft (23 patients) and the osteotomy site was internally fixed using proximal tibial T-plate. All patients were followed-up to 12 months after surgery. Anatomical indices of proximal tibia, complications of treatment, and functional outcome (using WOMAC osteoarthritis index) were assessed for both groups. Results. The amount of correction (degrees), recurrence of the deformity and loss of correction and time to clinical or radiologic union were similar in both groups with no statistically significant difference. Duration of operation was significantly less in allograft group (66.6±3.6 versus 52.9±5.3 minutes, p<0.001). Incidence of surgical site infection did not significantly differ in two groups. No nonunion or delayed union was encountered in either group. Some patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. Patients in both groups had statistically significant improvement in WOMAC index postoperatively (with no statistically significant difference between groups). Conclusions. According to the results of this study, iliac crest allograft may be safely used in medial opening-wedge high tibial osteotomy with comparable efficacy to iliac crest autograft in patients who do not accept the morbidity of autograft harvest

Over the last few decades, the All-Poly Monoblock Tibia has been relegated to a minimum use in the major healthcare systems of the western world. The main reason for this has been the perception that this tibial component is inferior in its ability to withstand stresses. This perception originated and subsequently gained ground, due to certain historical reasons, leading to the widespread use of the modular metal-backed tibial component despite a higher cost. The recent economic downturn has enforced even the rich western healthcare systems to look for cost-effective solutions. The author works in India, where the society is still highly price-sensitive and takes value for money very seriously. Further, the routine ADL of the Indian population requires them to adopt high flexion postures such as cross-legged sitting and squatting. The author has used the All-Poly Tibia extensively, which is the most economical of tibial components. Further, he has developed a surgical technique which has resulted in his patients achieving high flexion (greater than 135 degrees) in more than 75% cases. This paper presents the 10 year results of a series of 500 cases of Primary TKR in which the All-Poly Monoblock Tibia had been used. All the patients had cross-legged sitting activity as part of their ADL, thus presumably generating significant pressures on the joint surfaces. Of the original 500 cases, we could follow up 434 cases. We report a 96% survival rate of the implant in this series. There was not a single aseptic plastic failure. The revisions required were due to infection, peri-prosthetic fracture, and instability. The message being conveyed in this paper is that the All-Poly Tibia is a very cost-effective solution in routine Primary TKRs, and is able to deliver excellent long-term results even in high stress situations like cross-legged sitting activity. It would offer a huge cost savings to the healthcare system if the Orthopaedic Surgeons start using this implant more frequently

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty. We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group. The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial

Current military conflicts are characterised by the use of the Improvised Explosive Device (IED). Improvements in personal protection, medical care and evacuation logistics have resulted in increasing numbers of casualties surviving with complex musculoskeletal injuries, often leading to life-long disability. Thus, there exists an urgent requirement to investigate the mechanism of extremity injury caused by these devices in order to develop mitigation strategies. In addition, the wounds of war are no longer restricted to the battlefield; similar injuries can be witnessed in civilian centres following a terrorist attack.

Key to mitigating such injuries is the ability to deconstruct the complexities of an explosive event into a controlled, laboratory-based environment. In this study, an anti-vehicle underbelly injury simulator, capable of recreating in the laboratory the impulse from an anti-vehicle (AV) explosion, is presented and characterised. Tests were then conducted to assess the simulator's ability to interact with human cadaveric legs. Two mounting conditions were assessed, simulating a typical seated and standing vehicle passenger using instrumented cadaveric lower limbs.

This experimental device, will now allow us (a) to gain comprehensive understanding of the load-transfer mechanisms through the lower limb, (b) to characterise the dissipating capacity of mitigation technologies, and (c) to assess the biofidelity of surrogates.

Infection rates following arthroplasty surgery are between 1–4%, with higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are considerable, with significantly worse functional outcomes reported. New methods of infection prevention are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthoplasty cases.

Specimens from hip and knee arthroplasty infections are routinely collected to identify causative organisms. This study tested a range of these isolates for sensitivity to HINS-light. During testing, bacterial suspensions were exposed to increasing doses of HINS-light of (123mW/cm2 irradiance). Non-light exposed control samples were also set-up. Bacterial samples were then plated onto agar plates and incubated at 37°C for 24 hours before enumeration.

Complete inactivation was achieved for all Gram positive and negative microorganisms More than a 4-log reduction in Staphylococcus epidermidis and Staphylococcus aureus populations were achieved after exposure to HINS-light for doses of 48 and 55 J/cm2, respectively. Current investigations using Escherichia coli and Klebsiella pneumoniae show that gram-negative organisms are also susceptible, though higher doses are required.

This study has demonstrated that HINS-light successfully inactivated all clinical isolates from infected arthroplasty cases. As HINS-light utilises visible-light wavelengths it can be safely used in the presence of patients and staff. This unique feature could lead to possible applications such as use as an infection prevention tool during surgery and post-operative dressing changes.

Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. Methods and material. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. Results. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening). Discussion. Clinically, the three bearing types perform equally well at seven years, and there are few signs of impending failure for the stem. However, there are an alarmingly high proportion of cups showing signs of loosening. Two hips have been revised in the MOM group for aseptic loosening as opposed to none in the two other groups, which adds to the concern. The MOM articulation used in this study should be monitored closely for signs of aseptic loosening

Introduction. Anterior cruciate ligament reconstruction (ACLr) is the most widely published operation in the orthopaedic literature. Over recent years there has been increased interest in the surgical technique and role of concomitant procedures performed during ACLr. The National Ligament Registry (NLR) collects robust data on ACLr performed in the UK. In this registry analysis we explore trends in ACLr surgery and how they relate to published literature and the growing industry portfolio available to surgeons. Methods. Using data from the NLR, 14,352 ACLr performed between 2013–2021 were analysed. High impact papers on ACLr were then cross referenced against this data to see if surgical practice was influenced by literature or whether surgical practice dictated publication. Common trends were also compared to key surgical industry portfolios (Arthrex, Smith and Nephew) to see how new technology influenced surgical practice. Results. The number of ACLr performed in isolation is decreasing. The number of ACL reconstructions involving meniscal surgery shows an increasing trend since 2013, with 57% of ACLr in 2021 now involving meniscus surgery. The number of ACLr with lateral extra-articular tenodesis (LET) has increased sharply since 2018, preceding the stability trial publication in 2020. Graft preference and size has remained static despite the introduction of new graft harvest and fixation devices. Additional procedures such as other ligament reconstruction and additional cartilage surgery have also remained static over time. Conclusion. In this analysis we looked at surgical trends in ACLr and their relation to literature and industry. Meniscal intervention is increasing, in keeping with the growing level of literature in this area. In the setting of LET, a high impact level 1 study appears to have significantly changed the practice of UK surgeons with a sharp increase in the number of LET procedures being performed. Industry appears to have little influence on the change in surgical trends, suggesting high quality evidence is what drives innovation in ACLr while industry supports rather than influences innovation. It will be interesting to see the impact of the stability 2 study, recent work on the medial structures of the knee and the commissioning of cartilage centres on future trends

Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients. All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed. 28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p<0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction. This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522