Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77

Introduction. We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk. Material and methods. From 2004 to 2018, 257 patients (mean age: 67 years; range: 26–95) with a history of VTE underwent 277 primary, elective THAs procedures (128 right, 100 left, 9 single-stage bilateral, 20 staged bilateral) by two orthopaedic surgeons at a single institution. The patients had a history deep vein thrombosis (DVT) 186 (67%), pulmonary embolism (PE) 43 (15.5%), or both 48 (17.5%). Chemoprophylaxis included aspirin (38 patients) and anticoagulation (239 patients; Coumadin: 182, low-molecular-weight heparin: 3, clopidogrel: 1, rivaroxaban: 3, and a combination: 50). Forty eight patients (17.3%) had a vena cava filter at the time of surgery. Patients were followed for 120 days to detect complications, and for a year to detect mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. Bleeding complications occurred in 2 patients, one requiring surgical evacuation of a hematoma. Seven patients died during the first year (2.5%). One patient died 5 months postoperatively of a fatal PE during open thrombectomy, and one patient died of a hemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in any of the remaining 5 fatalities. Conclusions. The result of this study spanning over 13 years, suggests that MMP is safe and effective. Postoperative anticoagulation should be prudent as very few patients developed postoperative VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to VTE or bleeding. For any tables or figures, please contact the authors directly

There are many reports concerning the aetiology and prophylaxis of deep-vein thrombosis (DVT) but little is known about its natural history. The purpose of our study was to identify the incidence and site of DVT, the risk factors for pulmonary embolism and the natural history of DVT after total hip replacement (THR) in patients who do not receive any form of prophylactic or therapeutic treatment for DVT. Two hundred patients who had a primary THR were included: 100 had one-staged bilateral THR and 100 had unilateral THR and 150 implants were cemented and 150 cementless. Coagulation assays, a full blood count, blood typing and serum chemical profile tests were performed for all patients on three separate occasions. Bilateral simultaneous or unilateral venograms were performed on the sixth or seventh postoperative day and perfusion lung scans preoperatively and on the seventh or eighth postoperative day. Further venograms were performed in all patients who had thrombi six months later. In the patients with bilateral THR, 52 (26%) venograms were positive for thrombi, while in the patients with unilateral THR 20 (20%) were positive (p = 0.89). In the patients with a cemented THR, 31 venograms (20.7%) were positive for thrombi, while in those with a cementless THR 41 (27.3%) were positive (p = 0.654). Further venograms in all 72 patients who had thrombi at six months after operation showed that they resolved completely and spontaneously regardless of their site and size. No patients had symptoms of pulmonary emboli and none were seen on the perfusion lung scans. Two patients died from unrelated causes. Although the prevailing opinion is that patients with proximal venous thrombosis should be treated with anticoagulants, our study has shown that all thrombi regardless of their site and size resolve spontaneously without associated pulmonary embolism

Aims

There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA.

We studied 185 total hip replacements and related the identification of radiolucent lines (RLLs) at two years to the later development of lytic lesions and loosening. Linear polyethylene wear was also measured.

RLLs appeared in 34 hips at a mean of 2.0 years after operation, and lytic lesions in ten hips at 5.7 years. Of 151 THRs without RLLs there was neither rapid migration nor loosening and only one developed a possible lytic lesion. Of 23 hips with non-progressive RLLs there was neither rapid migration nor loosening, but six developed a lytic lesion. By contrast, 11 THRs with progressive RLLs migrated rapidly and seven developed a lytic lesion. Six THRs with progressive RLLs failed. The wear rates were the same in all groups, although limited numbers were available for study.

If the surgeon achieves secure initial fixation as shown by slow or no migration and no RLLs during the first two years, it is likely that no lytic lesions will develop by five years or aseptic loosening by ten years. If an imperfect, but adequate, interface is achieved, as shown by slow migration and non-progressive RLLs lytic lesions adjacent to the RLLs may develop by five years, but aseptic loosening will be unlikely at ten. Insecure initial fixation, as shown by more rapid migration and progressive RLLs at two years, is likely to lead to the formation of lytic lesions at five years and loosening at ten. The outcome after THR is therefore determined at the initial operation and may be predicted at two years. The presence of lytic lesions reflects soft tissue at the interface as shown by the RLLs which accompany and promote loosening but, in our study, did not cause it.

Aims. This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years’ clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results. The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion. Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low. Cite this article: Bone Joint J 2024;106-B(6):555–564

Aims. Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. Methods. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. Results. There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. Conclusion. We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320

Aims. Perthes’ disease (PD) is a childhood hip disorder that can affect the quality of life in adulthood due to femoral head deformity and osteoarthritis. There is very little data on how PD patients function as adults, especially from the patients’ perspective. The purpose of this study was to collect treatment history, demographic details, the University of California, Los Angeles activity score (UCLA), the 36-Item Short Form survey (SF-36) score, and the Hip disability and Osteoarthritis Outcome score (HOOS) of adults who had PD using a web-based survey method and to compare their outcomes to the outcomes from an age- and sex-matched normative population. Methods. The English REDCap-based survey was made available on a PD study group website. The survey included childhood and adult PD history, UCLA, SF-36, and HOOS. Of the 1,182 participants who completed the survey, the 921 participants who did not have a total hip arthroplasty are the focus of this study. The mean age at survey was 38 years (SD 12) and the mean duration from age at PD onset to survey participation was 30.8 years (SD 12.6). Results. In comparison to a normative population, the PD participants had significantly lower HOOS scores across all five scales (p < 0.001) for all age groups. Similarly, SF-36 scores of the participants were significantly lower (p < 0.001) for all scales except for age groups > 55 years. Overall, females, obese participants, those who reported no treatment in childhood, and those with age of onset > 11 years had significantly worse SF-36 and HOOS scores. Pairwise correlations showed a strong positive correlation within HOOS scales and between HOOS scales and SF-36 scales, indicating construct validity. Conclusion. Adult PD participants had significantly worse pain, physical, mental, and social health than an age- and sex-matched normative cohort. The study reveals a significant burden of disease on the adult participants of the survey, especially females. Cite this article: Bone Joint J 2022;104-B(12):1304–1312

Aims. Septic arthritis of the hip often leads to irreversible osteoarthritis (OA) and the requirement for total hip arthroplasty (THA). The aim of this study was to report the mid-term risk of any infection, periprosthetic joint infection (PJI), aseptic revision, and reoperation in patients with a past history of septic arthritis who underwent THA, compared with a control group of patients who underwent THA for OA. Methods. We retrospectively identified 256 THAs in 244 patients following septic arthritis of the native hip, which were undertaken between 1969 and 2016 at a single institution. Each case was matched 1:1, based on age, sex, BMI, and year of surgery, to a primary THA performed for OA. The mean age and BMI were 58 years (35 to 84) and 31 kg/m. 2. (18 to 48), respectively, and 100 (39%) were female. The mean follow-up was 11 years (2 to 39). Results. The ten-year survival free of any infection was 91% and 99% in the septic arthritis and OA groups, respectively (hazard ratio (HR) = 13; p < 0.001). The survival free of PJI at ten years was 93% and 99% in the septic arthritis and OA groups, respectively (HR = 10; p = 0.002). There was a significantly higher rate of any infection at ten years when THA was undertaken within five years of the diagnosis of septic arthritis compared with those in whom THA was undertaken > five years after this diagnosis was made (14% vs 5%, respectively; HR = 3.1; p = 0.009), but there was no significant difference in ten-year survival free of aseptic revision (HR = 1.14; p = 0.485). The mean Harris Hip Scores at two and five years postoperatively were significantly lower in the septic arthritis group compared with the OA group (p = 0.001 for both). Conclusion. There was a ten-fold increased risk of PJI in patients with a history of septic arthritis who underwent THA compared with those who underwent THA for OA with a ten-year cumulative incidence of 7%. The risk of any infection had a strong downward trend as the time interval between the diagnosis of septic arthritis and THA increased, highlighted by a 3.1-fold higher risk when THAs were performed within five years of the diagnosis being made. Cite this article: Bone Joint J 2022;104-B(2):227–234

Aims. A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients. Methods. TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA. Results. A total of 534 patients were randomized, with 233 in group 1, 235 in group 2, and 66 in group 3; 92 patients (17.2%) were considered high-risk. The mean IBL did not differ significantly between the two intervention groups (848.4 ml (SD 463.8) for group 1, and 843.7 ml (SD 478.7) for group 2; mean difference -4.7 ml (95% confidence interval -82.9 to 92.3); p = 0.916). No differences in mortality or incidence of VTE were observed between any group. Conclusion. The addition of oral TXA for 24 hours postoperatively does not reduce blood loss beyond that achieved with a single 1 g IV perioperative dose alone. There may be a clinically relevant difference in patients with a normal BMI, which warrants further investigation. Critically, there were no safety issues in patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(7):1197–1205

In 1975, Sweden started registering primary knee replacement surgeries based on the personal identity number. Individual-based registrations of primary total hip replacements started in 1992 and for hemiarthroplasties the registration started in 2006. The completeness of these registrations is estimated at 98% during the last 10-year period. The long history and high completeness allow for accurate calculations of population-based prevalence of joint replacement and trends over time. We used all data on primary joint replacements available in the Swedish Arthroplasty Register. The prevalence was calculated using number of alive patients with 1) at least one joint replacement 2) at least one hip replacement 3) at least one knee replacement at the end of each year from 2010 – 2021. Publicly available population numbers were retrieved from Statistics Sweden. We calculated total prevalence and prevalence per age in years. By the end of 2021, 3.2% of the Swedish population had at least one hip or knee replacement. This was an increase from 2.5% in 2010. Among 80-year-old, the prevalence was 17.5% for any joint replacement. For both hip and knee replacement and all ages, the prevalence was higher for women. For knee replacement, the 2021 prevalence peaked at the age of 89 (9,4%) while the prevalence continuously increased with age for hip replacements. A considerable proportion of the Swedish elderly population is living with at least one hip or knee replacement. The prevalence has increased during the last 12-year period for both hips and knees. An increasing prevalence may also affect the incidence of fractures and infections. Knowledge about the prevalence is fundamental for planning future demand for primary and revision hip and knee replacement

Aims. Perthes’ disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes’ disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes’ disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?. Methods. The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6). Results. Ages at onset of Perthes’ disease were < six years (n = 512; 43%), six to seven years (n = 321; 27%), eight to 11 years (n = 261; 22%), and > 11 years (n = 76; 6%), similar to the known age distribution of Perthes’ disease. During childhood, 40% (n = 476) of respondents had at least one surgery. Bracing, weightbearing restriction, and absence of any treatment varied significantly between USA and non-USA respondents (p < 0.001, p = 0.002, and p < 0.001, respectively). As adults, 22% (n = 261) had at least one total hip arthroplasty, and 30% (n = 347) had any type of surgery; both more commonly reported among women (p = 0.002). Conclusion. While there are limitations due to self-sampling, our study shows the feasibility of obtaining a large set of patient-reported data from adults who had childhood Perthes’ from multiple countries. Cite this article: Bone Jt Open 2022;3(5):404–414

Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l. Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. The extent of cardiovascular injury, measured by global longitudinal strain (GLS), in patients with elevated blood cobalt levels has not previously been examined. Sixteen patients with prospectively collected blood cobalt ion levels above 13µg/l were identified and matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. Patients underwent echocardiogram assessment including GLS. Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l compared to 0.01µg/l in the control group. There was no difference or correlation in EF, left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009). For the first time, this study has demonstrated reduced cardiac function in the presence of normal EF as assessed by GLS in patients with elevated cobalt above 13µg/l. As GLS is a more sensitive measure of systolic function than EF, routine echocardiogram assessment including GLS should be performed in all patients with MoM hip arthroplasties and elevated blood cobalt

Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates. A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed. Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria. Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction. These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%. The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent

LCPD can cause femoral head deformity and osteoarthritis requiring total hip replacement (THR). Currently, there is little data on how patients are functioning after a THR from patients’ perspective. The purpose of this study was to collect a large patient-reported outcome data set on adults with LCPD, including those who had a THR, using a Web-survey method and to compare their outcomes to a normative population. An English REDCap-based survey was built and made available on a LCPD study group website. The survey included childhood and adult LCPD history, SF-36 Health Survey, and the Hip Disability and Osteoarthritis Outcome Score (HOOS). Statistical analysis included t-test and linear and proportional odds regressions. Of the 1182 participants who completed the survey, 261 participants (89 M, 172 F) had a THR. The mean age at survey was 44.6±12.4 years (range 20–79). The mean duration since THR was 7.2±8 years (median 4, range 0–43). Gender and age matched analysis showed that THR participants had significantly lower HOOS Quality-of-Life and Sports scores (p<0.0001) for all age groups in comparison to a normative cohort. In women, the HOOS Symptoms, Daily Living, and Pain scores were also significantly lower in the <55 age groups (p<0.05). Similarly, SF-36 scores were significantly lower (p<0.05) in female <45 age groups in 5 out of 8 SF-36 scales. Overall, hip dysplasia and the number of years-from-THR were the main factors associated with worse SF-36 and HOOS scores. In comparison to the non-THR participants, THR participants had higher scores in some of the HOOS and SF-36 scales. LCPD participants with THR had significantly worse HOOS and SF-36 scores in most of the scales studied than a normative cohort, especially in women. There is significant disability even after a THR, warranting continued efforts to improve treatment and outcome

Dual mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a known rare complication of these implants and has reportedly decreased with modern implants. The purpose of this paper is to report the diagnosis and treatment of modern DM IPD. 1453 DM components were implanted between 2010 and 2021. 695 in primary and 758 in revision THA. 49 hips sustained a dislocation of the large head and 5 sustained an IPD at presentation. 6 additional IPD occurred at the time of reduction of large head. The average age was 64, 54% were female and the mean follow-up was three years. Of the 11 IPD, 8 had a history of instability, 5 had abductor insufficiency, 4 had prior lumbar fusion, and 3 were conversions from fracture. The overall IPD incidence was 0.76%. Ten of the 11 DM IPD were missed at initial presentation or at the time of reduction, and all were discharged with presumed reduction. The mean time from IPD to surgical treatment was 3 weeks. One patient died with an IPD at 5 months. A DM head was reimplanted in six, two underwent revision of the acetabular component with exchange of DM head, and four were revised to a constrained liner. The re-revision rate was 55% at a mean 1.8 years. None of the patients who underwent cup revision required subsequent re-revision while half of the constrained liners and exchange of DM heads required re-revision. The overall rate of DM dislocation or IPD is low. It is critical to identify an IPD on radiographs as it was almost universally missed at presentation or when it occurred iatrogenically. For patients presenting with IPD, the surgeon should consider acetabular revision and conversion to a constrained liner or a larger DM, with special attention to removing impinging structures that could increase the risk of re-dislocation

Satisfactory intermediate and long-term results of rotational acetabular osteotomy (RAO) for the treatment of early osteoarthritis secondary to developmental dysplasia of the hip have been reported. The purpose of this study is to examine the 30-year results of RAO. Between 1987 and 1994, we treated 49 patients (55 hips) with RAO for diagnosis of pre- OA or early-stage OA. Of those patients, 35 patients (43 hips) were available at a minimum of 28 years. The follow-up rate was 78.2% and the mean follow-up was 30.5 years. The mean age at the time of surgery was 34 years. Clinical evaluation was performed with the Merle d'Aubigne and Postel rating scale, and radiographic analyses included measurements of the center-edge angle, acetabular roof angle, and head lateralization index on preoperative, postoperative AP radiographs of the pelvis. Postoperative joint congruency was classified into four grades. The radiographic evidence of progression of OA was defined as the minimum joint space less than 2.5mm. The mean preoperative clinical score was 14.0, which improved to a mean of 15.3 at the time of the latest follow-up. The mean center-edge angle improved from 0.6° preoperatively to 34° postoperatively, the mean acetabular roof angle improved from 28.4°preoperatively to 1.0°postoperatively, the mean head lateralization index improved from 0.642 preoperatively to 0.59 postoperatively. Postoperative joint congruency was excellent in 11 hips, good in 29 hips, and fair in 3 hips. Nineteen patients (20 hips) had radiographic OA progression, and 10 patients (11 hips) were converted to THA. Kaplan-Meier survivorship analysis, with radiographic OA progression as the end point, predicted survival of 75.6% at 20 years and 48.8% at 30 years, and with THA conversion as the end point, 90.2% at 20 years and 71.2% at 30 years. The RAO is an effective surgical procedure for symptomatic dysplastic hips of pre- and early-stage OA and could change the natural history of the dysplastic hip

Our understanding of pre-arthritic hip disease has evolved tremendously but challenges remain in categorizing diagnosis, which ultimately impacts choice of treatments and clinical outcomes. This study aims to report patient reported outcome measures (PROMs) comparing four different condition groups within hip preservation surgery by a group of fellowship-trained surgeons. From 2018 to 2021, 380 patients underwent hip preservation surgery at our center and were classified into five condition groups: dysplasia: 82 (21.6%), femoro-acetabular impingement (FAI): 173 (45.4%), isolated labral tear: 103 (27.1%), failed hip preservation: 20 (5.3%) and history of childhood disease/other: 2 (0.5%). International hip outcomes Tool 12 (IHOT-12), numeric pain score and patient-reported outcomes measurement information system (PROMIS) were collected pre-operatively and at 3 months and 1 year post-operatively, with 94% and 82% follow-up rate respectively. Arthroscopy (75.5%) was the most common procedure followed by peri-acetabular osteotomy (PAO) (22.4%) and surgical dislocation (2.1%). Re-operation rate were respectively 18.3% (15), 5.8% (10), 4.9% (5), 30% (6) and 0%. There were 36 re-operations in the cohort, 14 (39%) for unintended consequences of initial surgery, 10 (28%) for mal-correction leading to a repeat operation, 8 (22%) progression of arthritis, and 4 (11%) for incorrect initial diagnosis/intervention. Most common re-operations were hardware removal 31% (7 PAO, 3 surgical hip dislocation and 1 femoral de-rotational osteotomy), arthroscopy 31% (11) and arthroplasty 28% (10). All groups had significant improvements in their IHOT-12 as well as PROMIS physical and numerical pain scales, except those with failed hip preservation. Dysplasia group showed a slower recovery. Overall, this study demonstrated a clear relation between the condition groups, their respective intervention and the significant improvements in PROMs with isolated labral pathology being a valid diagnosis. Establishing tertiary referral centers for hip preservation and longer follow-up is needed to monitor the overall survivorship of these various procedures

Surgical management of acetabular fractures in older patients remains controversial. The purpose of this study is to compare outcomes of primary THA with outcomes after THA for acute acetabular fractures (aTHA) as well as outcomes following delayed THA (dTHA) following prior acetabular fracture. We analyzed data from a large, national administrative claims database containing diagnostic, procedural, and demographic records from over 157 million patients. We identified all patients undergoing primary total hip arthroplasty THA continuously enrolled in the database at least 2 years prior and after the index procedure. Patients with an initial diagnostic code for acetabular fracture occurring the same day as the THA were classified as acute acetabular fractures. Patients with an initial acetabular fracture diagnostic code occurring at least 6 months before THA were classified as chronic acetabular fractures. The comparator group was patients undergoing THA with no history of acetabular fracture. There were 426,734 patients undergoing primary THA, 235 patients undergoing aTHA and 1,255 patients undergoing dTHA. Patients with an aTHA had higher complication rates, including revisions (9.8% vs 5.6%,), dislocations (8.9% vs 6.4%), and periprosthetic fracture (5.1% vs 2.3%) compared to dTHA. After adjusting for age, sex, region, and comorbidities, receiving an aTHA increased the odds of revision (OR = 3.65 [95% CI: 2.30–5.49]), dislocation (OR = 4.09 [95% CI: 2.53–6.27]), and periprosthetic fracture (OR = 4.29 [95% CI: 2.26–7.36]) compared to primary THA. Receiving a dTHA significantly increased the odds of revision (adjusted OR = 1.80 [95% CI: 1.40–2.27]), dislocation (adjusted OR = 2.50 [95% CI: 1.97–3.13]), and periprosthetic fracture (adjusted OR = 1.99 [95% CI: 1.34–2.83]) compared to primary THA. Patients undergoing aTHA in the treatment of an acetabular fracture have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to dTHA and primary THA

Elevated blood cobalt secondary to metal-on-metal (MoM) hip arthroplasties has been shown to be a risk factor for developing cardiovascular complications including cardiomyopathy. Published case reports document cardiomyopathy in patients with blood cobalt levels as low as 13µg/l (13ppb, 221nmol/l). Clinical studies have found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Global longitudinal strain (GLS) is an echocardiography measurement known to be more sensitive than ejection fraction at diagnosing early cardiomyopathies. The extent of cardiovascular injury, as measured by GLS, in patients with elevated blood cobalt levels has not previously been examined. Sixteen patients with documented blood cobalt ion levels above 13µg/l were identified from a regional arthroplasty database. They were matched with eight patients awaiting hip arthroplasty with no history of cobalt implants. All patients underwent electrocardiogram and echocardiogram assessment for signs of cardiomyopathy including GLS. Patients with MoM hip arthroplasties had a mean blood cobalt level of 29µg/l (495nmol/l) compared to 0.01µg/l (0.2nmol/l) in the control group. There was no difference or correlation in ejection fraction (EF), left ventricular (LV) end systolic dimension, LV end diastolic dimension, fractional shortening, ventricular wall thickness or E/e’ ratio. However, GLS was significantly reduced in patients with MoM hip arthroplasties compared to those without (−15.2% v −18%, (MoM v control) p= 0.0125). Pearson correlation demonstrated that GLS is significantly correlated with blood cobalt level (r= 0.8742, p=0.0009). For the first time, this study has demonstrated reduced cardiac function in the presence of normal EF as assessed by GLS in patients with elevated cobalt above 13µg/l. As GLS is a more sensitive measure of systolic function than EF, routine echocardiogram assessment including GLS should be performed in all patients with MoM hip arthroplasties and elevated blood cobalt above 13µg/l. Further work is recommended to assess if these cardiac changes are present in patients with elevated blood cobalt levels below 13µg/l