‘Getting It Right First Time’ guidance recommends the universal use of cemented prostheses in patients aged over 65 within the UK. This cut off has since been raised to 70. The report claims that the increased cost of uncemented technology is not justifiable in terms of patient outcomes. Our aim was to evaluate any disparity between patients across these age thresholds, in terms of functional outcomes, complication and costs following elective uncemented THR. We utilised a single surgeon prospectively updated database, to compare functional outcome of patients aged over and under 65 and again at 70 following elective uncemented THR. We measured functional outcome using Oxford Hip Score (OHS). Patients were followed routinely for up to 2 years and subsequently up to 6 years. Patient ages ranged from 23–89. Over 97% of patients reported an improvement in hip function, with an average increase of 24.1 in OHS. There was no statistical significance between patient age and functional hip outcome, p=0.108 with a cut off at 65 and p=0229 at 70. 1.1% of under 65s required revision surgery, compared to 2.3% of over 65s. 1.4% of patients under 70 required revision surgery, compared to 2.5% in those above. The most common reason for revision surgery was debridement, antibiotics and implant retention. Patients under 65 had a 1.4% chance of experiencing a fracture or dislocation, compared to 2.5% of patients over 65. 2.0% of patients under 70 experienced a fracture or dislocation, in comparison to 2.2% in those over 70. There was 1 recorded mortality, a patient aged over 70. Cost analysis is challenging accounting for all variables between techniques. Cementing invariably requires additional operating time and diminished theatre efficiency, with direct cost estimated at £364 in theatre running fees per case. Within the series, uncemented THRs was found to be a safe and efficacious procedure irrespective of age. Functional hip outcome was not correlated to patient age, conflicting with GIRFT recommendations. The extra duration of cemented surgery may equilibrate the financial disparity of uncemented practice

Background. In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless. Aim. To assess differences in patient reported outcomes in uncemented THAs based on patient demographics in order to decide when cementless THA can be done safely. Method. Prospective data collection of consecutive 1079 uncemented THAs performed for 954 patients in single trust between 2010 and 2020. Oxford Hip Score (OHS) and complications were analysed against demographic variables (age, sex, BMI, ASA) and prosthesis features (femoral and acetabular size, offset and acetabular screws). Results. The mean pre-operative OHS was 14.6 which improved to 39.0 at 1 year follow up (P Value=0.000). There was no statistically significant difference between OHS outcome in patients aged over 70 versus younger groups. With a small number of revisable complications increase with age from 50s upwards. Male patients’ OHS score was on average 2.4 points higher than women. Men, however were 2.9 times more likely to experience fractures and high offset hips were 2.5 times more likely to experience dislocations. DAIR, intraoperative calcar fractures, post-operative fractures and dislocations were not associated with worse OHS. Patients with increased BMI had worse pre and post-operative hip functions yet, there was a significant multivariate association between increased BMI and increased improvement in OHS from pre-op to 1 year in women aged 55–80 and men under the age of 60. Femoral stem size increases with age but decreases in male patients over 80. There was no difference found in OHS between bilateral hip replacements and unilateral, nor was there any change found with laterality side of the replacement. Conclusions. This study suggests that ageing >70 is not associated with poorer outcomes despite small number of revisable complication rates that increase with age from 50 upwards. Men had marginally higher average OHS than women At 1 year. Higher BMI or ASA scores are associated with worse pre-operative hips and worse final outcome score. Despite this, the Delta OHS increases with increased BMI shown in the 55–80 year old female patients and male patients under 60. Key Words: THR, Uncemented, Oxford hip score, outcome

Femoroacetabular impingement (FAI) is a condition of the hip where there is a mismatch of the femoral head and hip acetabulum. This mismatch creates abnormal contact between the bones and causes hip pain which can lead to damage, and eventually osteoarthritis of the hip. The diagnosis and treatment of FAI has become one of the most popular clinical scenarios in orthopaedic surgery, with hip arthroscopy procedures increasing exponentially over the past five years. Surgical intervention usually involves correcting the existing deformities by reshaping the ball and socket (“osteoplasty” or “rim trimming”) so that they fit together more easily while repairing any other existing soft tissue damage in the hip joint (e.g. labral repair). Although correction of the misshaped bony anatomy and associated intra-articular soft tissue damage of the hip is thought to appease impingement and improve pain and function, the current evidence is based on small, observational, and low quality studies. A lack of definitive evidence regarding the efficacy of osteochondroplasty in treating FAI fueled the design and execution of the FIRST randomized controlled trial (RCT). FIRST evaluated the impact of surgical correction of the hip impingement morphology with arthroscopic osteochondroplasty versus arthroscopic lavage on pain, function, and quality of life in adults aged 18–50 years diagnosed with non-arthritic FAI at one year. FIRST was a large definitive RCT (NCT01623843) enrolling patients with FAI requiring surgical intervention across 11 international clinical sites. Participants were randomized to either arthroscopic osteochondroplasty (shaving of bone) or lavage (washing the joint of painful inflammation debris). The primary outcome was patient-reported pain within one year of the initial surgery measured using the Visual Analogue Scale (VAS). Secondary outcomes included function, health utility, and health-related quality of life using several general and hip-centric health questionnaires. An independent, blinded adjudication committee evaluated the quality of surgery, re-operations, and other patient complications. Patients and data analysts were blinded to the treatment groups. Two-hundred and twenty participants were enrolled into the FIRST trial over a six-year period (pilot phase: N=50, from 2012–2013 and definitive phase: N=170, from 2015–2018) at 11 clinical sites in Canada, Finland, and Denmark. The FIRST results will be released at the ISAKOS annual meeting as follows. The absolute difference in rate of pain reduction between groups was XX (95% CI: YY-YY, p=X). The mean differences of the Short-Form 12 (SF-12, MCS and PCS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and EuroQol 5-Dimensions (EQ-5D) between groups are XX (95% CI: YY-YY, p=X)…, respectively. Reoperations occurred in XX of 220 (X%) patients over the one-year follow up period (OR:XX, 95% CI: YY-YY, p=X) and the patients treated with arthroscopic osteochondroplasty conferred the following risk of reoperation within one-year compared to arthroscopic lavage (RR:XX, 95% CI: YY-YY, p=X). This RCT represents major international efforts to definitively identify the optimal treatment strategy for FAI. The results of this trial will change practice, being used to prevent chronic hip pain and loss of function caused by hip osteoarthritis

We present a prospective two-year follow-up study of 1038 hip arthroscopies performed at a high volume tertiary referral centre for hip preservation. We feel that this manuscript is both pertinent and timely due to the advances in the field of hip preservation. We used four validated patient-reported outcome (PRO) scores along with the visual analog scale (VAS) and patient satisfaction scores to assess preoperative and postoperative outcomes in all patients undergoing hip arthroscopy. We divided the entire cohort into patients undergoing primary and revision hip arthroscopies. We found a statistically significant improvement from preoperative to two-year postoperative PRO scores in the two subgroups. We also found a significant difference in the PRO scores at three months, one year, and two years postoperatively between the primary and revision subgroups. The revision subgroup had inferior VAS and patient satisfaction compared to the primary subgroup, however these results were not significant. The conversion to total hip arthroplasty/hip resurfacing (THA/HR) was 5.6% and 11.2% in the primary and revision subgroups, respectively. This resulted in a relative risk of 2.0 for conversion to THA/HR in the revision subgroup. We had a complication rate of 5.3 (only 0.5% of which were considered major) which was similar to that reported in the literature for hip arthroscopy. The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopy at a high volume tertiary referral centre for hip preservation with minimum two-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopy. From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopy. Patients were assessed pre- and post-operatively with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. There were a total of 1155 arthroscopies performed, including 1040 primary arthroscopies (926 patients) and 115 revision arthroscopies (106 patients). Of these, 931 primary arthroscopies (89.5%) in 824 patients (89.0%) and 107 revision arthroscopies (93.0%) in 97 patients (91.5%), were available for follow-up and included in our study. The mean change in patient reported outcome (PRO) scores at two-year follow-up in the primary subgroup was 17.4 for mHHS, 19.7 for HOS-ADL, 23.8 for HOS-SSS, 21.3 for NAHS, and −3.0 for VAS. The mean change in PRO scores at two-year follow-up in the revision subgroup was 13.4, 10.9, 16.1, 15.4, and −2.7, respectively. All scores improved significantly compared to pre-operatively (p<0.001). PRO scores were higher at all time points for the primary subgroup compared to the revision subgroup (p<0.05). Satisfaction was 7.7 and 7.2 for primary and revision subgroups, respectively. Of 931 primary arthroscopies, 52 (5.6%) underwent THA/HR. Of 107 revision arthroscopies, 12 (11.2%) underwent THA/HR. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures. The overall complication rate was 5.3%. Hip arthroscopy showed significant improvement in all PRO, VAS, and satisfaction scores at two years postoperatively. Primary arthroscopy patients showed greater PRO scores and a trend towards greater VAS compared to the revision subgroup. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures

The outcomes of hip arthroscopy in the treatment of dysplasia are variable. Historically, arthroscopic treatment of severe dysplasia (lateral center-edge angle [LCEA] < 18°) resulted in poor outcomes and iatrogenic instability. However, in milder forms of dysplasia, favorable outcomes have been reported. The purpose of this study was to compare outcomes following hip arthroscopy for femorocetabular impingement (FAI) in borderline dysplastic (BD) patients compared with a control group of non-dysplastic patients. Between March 2009 and July 2012, a BD group (LCEA 18°–25°) of 46 patients (55 hips) was identified. An age and sex-matched control group of 131 patients (152 hips) was also identified (LCEA 25°–40°). Patient-reported outcome scores, including the Modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL), the Sport-specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected pre-operatively, at 1, and 2 years. The mean LCEA was 22.4 ± 2.0° (range, 18.4°–24.9°) in the BD group and 31.0 ± 3.1° (range, 25.4°–38.7°) in the control group (p<0.001). The mean preoperative alpha angle was 66.3 ± 9.9° in the BD group and 61.7 ± 13.0° in the control group (p=0.151). Cam decompression was performed in 98.2% and 99.3% of cases in the BD and control groups. Labral repair was performed in 69.1% and 75.3% of the BD and control groups respectively, with 100% of patients having a complete capsular closure performed in both groups. At a mean follow-up of 31.3 ± 7.6 months (range, 23.1–67.3) in unrevised patients and 21.6 ± 13.3 months (range 4.7–40.6) in revised patients, there was significant improvement (p<0.001) in all patient reported outcome scores in both groups. Multiple regression analysis did not identify any significant differences between groups. Importantly, female sex did not appear to be a predictor for inferior outcomes. Two patients (4.3%) in the BD group and six patients (4.6%) in the control group required revision arthroscopy during the study period. Favorable outcomes can be expected following the treatment of impingement in borderline dysplastics when labral refixation and capsular closure are performed, with comparable outcomes to non-dysplastic patients. Further follow-up in larger cohorts is necessary to prove the durability and safety of hip arthroscopy in this challenging group and to further explore potential gender-related differences in outcome

Introduction. Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. Methods. 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Results. 151 of 244 (62%) patients reported a history of back problems: 35 patients (14%) – history of lumbar surgery, 91 (37%) – daily low back pain, and 97 (40%) – back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without, p=0.0001. Pain relief was reported by 93% versus resumption of activities in 82% of THA patients, p=0.025. Increasing spine disability, as determined by ODI, correlated with poor OHS, p<0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R=0.41, p<0.0001), return to activity (R=0.34, p<0.0001), and overall surgical results (ODI, R=0.38, p<0.0001) at 2 years after THA. Patient age, gender, and BMI were not associated with poor THA outcomes. Conclusions. The majority of THA patients have a history of lumbar spine problems. The Oswestry Spine Disability Index, which is the primary outcome measure of spinal disorders, correlated strongly with poor THA outcomes. Moderate and severe lumbar spine disability directly correlated with worse Oxford Hip Scores. Spine disability was directly associated with THA dissatisfaction

Background. A consecutive series of 76 patients (101 hips) underwent primary open reduction, capsulorrhaphy and innominate osteotomy for late presenting developmental hip dislocation. They were aged 1.5 to 5 years at the time of surgery between 1958 and 1965. This study was designed to review their outcome into middle age. Methods. We located and reviewed 60 patients (80 hips) using a public records search. This represents a 79% rate of follow-up at 40-48 years post-operatively. 19 patients (24 hips) had undergone total hip replacement and 3 had died. The remaining 38 patients (53 surviving hips) were assessed by the WOMAC. ¯. and Oxford hip outcome questionnaires, physical examination and standing pelvic radiograph. The radiographs were analysed for minimum joint space width and the Kellgren and Lawrence score. Accepted indices of hip dysplasia were measured. Results. Kaplan-Meier survival analysis is presented using the end point of total hip replacement. Survival rates at 30, 40 and 45 years post-reduction are 99% (95% CI +/−2.4), 86% (+/− 6.9) and 54% (+/−16.4) respectively. Average Oxford and WOMAC. ¯. scores for surviving hips were 16.8 (range 0-82) and 16.7 (range 0-71) respectively. Of 51 surviving hip radiographs, 38 had a minimum joint space width in excess of 2.0mm, 13 had definite osteoarthritis (OA) on this criterion. 29 were Kellgren and Lawrence grade 0/1(no or doubtful signs of OA), 7 grade 2 (mild OA), 15 grade 3 or 4 (moderate or severe OA). The average centre-edge and acetabular angles were 40° (range 0-61°) and 32° (20-43°) respectively. There was no significant association between outcome and the modifiable risk factors of body mass or age at surgery. Conclusion. This method of treatment achieves a 54% rate of hip survival at 45 years. Two thirds of surviving hips have an excellent prognosis at this stage

The effect of early surgery on hip fracture outcomes has received considerable study and although it has been suggested that early surgical treatment of these fractures leads to better patient outcomes, the findings are inconclusive. The American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP) prospectively collects blinded, risk-adjusted patient-level data on surgical patients in over 600 participating hospitals worldwide. The primary objective of this study was to determine the proportion of ACS-NSQIP hospital patients that are currently being treated within the UK's National Institute for Health and Care Excellence (NICE) time to hip fracture surgery benchmark. The secondary objectives were to identify risk factors for missing the benchmark, and determine if the benchmark is associated with improved 30-day patient outcomes. Patients that underwent hip fracture surgery between 2005–2013 and entered in the ACS-NSQIP database were included in the study. Counts and proportions were used to determine how frequently the NICE benchmark was met. Multivariate regression analysis was used to identify significant predictors of missing the NICE benchmark and determine if missing the benchmark was associated with 30-day mortality/complications rates. 26,006 patients met the study enrolment criteria. 71.4% of patients were treated within the NICE benchmark and 89.4% were treated by post-admission day two. Gender, dyspnea, infectious illness, bleeding disorders, preoperative hematocrit, preoperative platelet count, arthroplasty procedure type, race other than White, and hip fracture diagnosis were all statistically significant predictors of missing the benchmark (p<0.01). Meeting the NICE benchmark was not associated with reductions in major complications (OR=0.93, CI=0.83–1.05, p=0.23), nor a clinically significant difference in postoperative length of stay (LOS) (parameter estimate=0.77, p<0.01); however, it was associated with a decreased 30-day mortality (OR=0.88, CI=0.78–0.99, p=0.03) and the likelihood of minor complications (OR=0.92, CI=0.84–0.995, p=0.04). ACS-NSQIP hospitals are currently compatible with the NICE benchmark. However, data from the ACS-NSQIP database suggests that surgical treatment within the NICE benchmark may be unnecessarily narrow. Extending the benchmark to post-operative day two did not significantly increase the risk of 30-day mortality and minor complications; nor did it extend the average LOS. Neither the NICE benchmark, nor the extended two-day standard, was associated with reductions in major complications. The findings highlight the importance of further prospective investigation to monitor the effect of time to surgery benchmarks

Background. There is increasing interest in the use of Total Hip Replacement (THR) for reconstruction in patients who have suffered displaced intracapsular hip fractures. Patient selection is important for good outcomes but criteria have only recently been clearly defined in the form of national guidelines. This study aims to investigate patient reported outcomes and satisfaction after Total Hip Replacement (THR) undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis in order to assess the safety and effectiveness of national clinical guidelines. Methods. 100 patients were selected for treatment of displaced hip fractures using THR between 1 January 2007 and 31 December 2009. These patients were selected using national guidelines and were matched for age and gender with 300 patients who underwent contemporaneous THR as an elective procedure for osteoarthritis. Results. Patients undergoing THR for both fracture and as an elective procedure reported excellent outcomes and satisfaction. Hip fracture patients had better post-operative Oxford hip scores (p< 0.001) and SF-12 physical component scores (p< 0.001). Mental component scores were poorer for hip fracture patients (p< 0.001). In this series, the rates of major complications for hip fracture patients were higher than for elective patients. Nevertheless, the rates of dislocation, deep infection and early revision surgery were similar to those widely reported in the literature and considered within acceptable limits after elective surgery. Conclusions. For selected patients, THR undertaken for displaced fractures of the hip produces outcomes which are at least equivalent to those achieved after elective surgery. Selection is critical to this success and the extended use of current guidelines is appropriate and safe

We have a national UK database for hip fracture outcome. It has been developed synchronously with an agreed care pathway that is multi-disciplinary, including surgeons, anaesthetists, geriatricians, osteoporosis experts, healthcare managers and lay charities. Care has been improved and audit established for future evolution. The database started in 2007 and now includes 85 units. The synchronous care pathway deals with falls and osteoporosis prevention, perioperative multi-disciplinary care, rehabilitation and outcome results. Key issues are avoidance of delay and cancellation of surgery and how we deal with patients with medical co-morbidities. Outcome is analysed prospectively to take account of co-morbidities and variations in surgical techniques. The care pathway and data base are now universally accepted as a national priority with advice for all UK trauma units to participate. Of the 121 registered units, only 85 actively contribute data. The cost and staff needs for data input are now accepted. To date, 12,983 clinical cases have been entered. Variation of trauma theatre list operating time per head of population and other related resource has been highlighted. This has been accepted by politicians and health managers. The NHS Institute of Improvement has started a rapid improvement plan to support units with poor resource/audit outcome. It is early days in terms of validity of outcome data for technical variations in treatment eg. fixation/replacement/use of bone cement. We have a national increase in resouce for hip fractures. We now have some logic to interaction between surgeons and medics/managers. Objectively struggling units get active support. We accept the possible lack of validity of some outcome data. Some units who look bad on paper should not be disadvantaged

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.