Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR. . Cite this article: Bone Joint J 2014; 96-B:1464–71

Aims. During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. Methods. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Results. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Conclusion. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136–1145

Background

There remains a paucity of clinical studies on the effects of coronavirus on perioperative outcomes, with no existing trials reporting on risk factors associated with increased risk of postoperative mortality in these patients. The objectives of this study were to assess perioperative complications and identify risk factors for increased mortality in patients with coronavirus undergoing surgery.

Partial thickness abductor tendon tears are a significant source of recalcitrant laterally based hip pain. For those that fail conservative treatment, the results of endoscopic repair are highly successful with minimal morbidity. The principal burden is the protracted rehabilitation that is necessary as part of the recovery process. There is a wide gap between failed conservative treatment and successful surgical repair. It is hypothesized that a non-repair surgical strategy, such as a bioinducitve patch, could significantly reduce the burden associated recovery from a formal repair. Thus, the purpose of this study is to report the preliminary results of this treatment strategy. Symptomatic partial thickness abductor tendon tears are treated conservatively, including activity modification, supervised physical therapy and ultrasound guided corticosteroid injections. Beginning in January 2022, patients undergoing hip arthroscopy for intraarticular pathology who also had persistently symptomatic partial thickness abductor tendon tears, were treated with adjunct placement of a bioinducitve (Regeneten) patch over the tendon lesion from the peritrochanteric space. The postop rehab protocol is dictated by the intraarticular procedure performed. All patients are prospectively assessed with a modified Harris Hip Score (mHHS) and iHOT and the tendon healing response examined by ultrasound. Early outcomes will be presented on nine consecutive cases. Conclusions - Will be summarized based on the preliminary outcomes to be reported

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed. 8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE. Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

Periprosthetic joint infection is a serious complication of primary total hip replacement (THR) with significant associated morbidity. In acute infection, Debridement, Antibiotics and Implant Retention (DAIR) may be considered. Current national guidelines recommend a DAIR should be performed by “an experienced arthroplasty surgeon┕ but do not specify the need for this to be a revision arthroplasty surgeon. We investigated outcomes in our NHS Trust of DAIR procedures performed by revision and non-revision arthroplasty surgeons. Infection registry data and patient records were analysed for all DAIR procedures of infected primary THRs between 2017 and 2021. Data collected included details of the primary surgery, the presentation with infection, the DAIR procedure and any subsequent complications including return to theatre at any time point. Routinely collected pre- and post-operative patient reported outcome measures (PROMs) were reviewed. 54 periprosthetic joint infections of primary THRs received a DAIR procedure. 41 DAIRs were performed by a revision surgeon and 13 by non-revision surgeons. There was no significant difference in time from primary THR to presentation with infection, time from presentation to DAIR or pre-operative C-reactive protein between the two groups. In 21 (38.9%) patients the DAIR procedure was classed as a treatment failure; 17 patients (31.5%) returned to theatre for further revision surgery, one (2.4%) died related to infection and three (5.6%) had persistent infection but did not receive further surgery. Treatment failure was significantly higher in the non-revision surgeon group (9/13 (69.2%)) than in the revision surgeon group (12/41 (29.3%)) (p = 0.02). Overall, improvement in PROMs after DAIR was seen at both six and 12 months. The overall success rate of DAIR was 61.1% and there was a sustained improvement in PROMs after surgery. However, there was a significant difference in failure rates between revision surgeons and non-revision surgeons

Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11). In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation. A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database. In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%. In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system

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

Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF). This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel. Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA. This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique

Patients with a high comorbidity burden (high-risk) can achieve similar improvements in quality of life compared to low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences THA outcomes in high-risk patients has not been investigated. This study aimed to compare complication rates and implant survivorship in high-risk patients operated on by high volume (HV) and non-HV THA surgeons. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologist Classification of 3 or 4 undergoing primary, elective THA between 2013 and 2021 were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Ninety day readmissions and revisions were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Years of experience were comparable between Non-HV and HV surgeons (p=0.733). The HV group had significantly shorter surgical times (p<0.001), and shorter length of stay (p=0.009) compared to the Non-HV group. The HV group also had significantly fewer 90-day readmissions (p=0.030), all-cause revisions (p=0.023) and septic revisions (p=0.020) compared to the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p=0.023) and septic revision (p=0.020) compared to the non-HV group. High-risk THA patients have fewer 90-day readmissions, all-cause revisions, septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a high comorbidity burden may benefit from referral to high-volume surgeons to reduce procedural risk and improve postoperative outcomes

The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive . Staphylococcus Aureus. (MSSA) is the most frequent organism, and the majority are endogenous. Nasal MSSA colonisation is a proven risk factor for S. aureus infection. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI. Our hospital trust introduced MSSA screening and decolonisation prior to hip and knee arthroplasty in 2010. Data was prospectively collected since 2013, including all MSSA carriers, decolonisation treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used. During the study period 15,958 primary hip and knee replacements were performed. 3,200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1,210 neomycin and 1,221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P<0.0001). There was no difference in S. aureus PJI rates (P=0.452). Of those negative at original screening 9.1% were positive on the day of surgery (1,164/12,758). MSSA decolonisation is an effective method to decrease PJI rates but there is little research into the best treatment. Both mupirocin and neomycin are more effective than octenidine at achieving MSSA decolonisation. There was poor correlation between the MSSA status after treatment and PJI rates. There is debate if treatment should be targeted by screening or if all patients she be treated without screening. Global decolonisation without screening is supported by the 26.7% of carriers that were negative at original screening in our study. Further research is needed comparing decolonisation treatments to reduce PJI rates and avoid the risk of drug resistance

Total Hip Replacements (THR) and Hip Hemiarthroplasties (HA) are both successful and common orthopaedic procedures. Dislocation is a well-recognised complication carrying significant morbidity and, in some cases, increased mortality risks. We define prosthetic hip dislocations (PHDs) to include both THRs and HAs. Prosthetic Hip Dislocations (PHDs) are a common acute admission yet there are no published guidelines or consensus on management following reduction. A retrospective audit was undertaken by the North West Orthopaedic Research Collaborative (NWORC) between January 2019 and July 2019. A questionnaire was used to capture the management of each dislocation episode presenting to 11 Hospital trusts. The study was registered as a Quality Improvement (QI) project at each site. Data regarding the surgical management physiotherapy input, ongoing care and further management plans were recorded. A total of 183 patients with 229 dislocations were submitted for initial analysis (171 THRs, 10 HAs, 2 PFRs). Female to male ratio was 2:1 with mean age of 76.7 years. Average time to first dislocation was 8.1 years. 61.1% were first or second time dislocators and 38.9% presented with 3 or more dislocations. Initial reductions were predominantly attempted in theatre (96.5%, n=221) with only 3.5% (n=8) attempted in the emergency department. In theatre 89% (n=201) were reduced closed. There was no plan for revision surgery in 70.6% cases with no difference seen between patients with >=3 dislocations and <=2 dislocations. Of the patients with a revision plan, 71% of these were performed or planned locally. The high number of patients with 3 or more dislocations and the lack of plans for definitive interventions in the majority of cases highlights the significant variation in the management of this complex group of patients. This variation in the quality of care increases the burden on the National Health Service through repeat hospital episodes. We aim to roll out this study nationally to assess regional variations and ultimately make the case for national guidance on the management of prosthetic hip dislocations

Aims. Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique. Methods. We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases. Results. Seven patients (7.9%) required further revision for infection. Ten patients died of causes unrelated to their infection before their two-year review (mean 5.9 months; 0.9 to 18.6). One patient was lost to follow-up at five months after surgery, and two patients died of causes unrelated to their hip shortly after their two-year review was due without attending. Of the remaining patients, 69 remained infection-free at final review. Radiological review confirms the mechanical success of the procedure as previously described in aseptic revision, and postoperative Oxford Hip Scores suggest satisfactory functional outcomes. Conclusion. In conclusion, we found that retaining a well-fixed femoral cement mantle in the presence of infection and undertaking a cement-in-cement revision was successful in 82 of the patients (92.1%) in our series of 89, both in terms of eradication of infection and component fixation. These results are comparable to other more invasive techniques and offer significant potential benefits to the patient. Cite this article: Bone Joint J 2022;104-B(2):212–220

Introduction. Prosthetic joint infection (PJI) is an devastating complication after total hip arthroplasty (THA). The common treatment in the US is a two-stage exchange which can be associated with significant morbidity and mortality. The purpose of this study was to analyze complications in the treatment course of patients undergoing two-stage exchange for PJI THA and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI after THA from January 2005 – December 2017 at a single institution. Complications were categorized as medical or surgical, divided into three intervals: (1) inter-stage, (2) early post-reimplantation (<90 days) and (3) late post-reimplantation (> 90 days). Minimum follow up was one year. Success was based on the Musculoskeletal Infection Society (MSIS) definition. Results. 185 hips underwent first stage of planned two stage exchange. The median age was 65 (IQR 18). There were 93 males and 92 females. 73 patients had a complication during treatment. 13.5% (25/185) of patients experienced a medical complication and 28.1% (52/185) a surgical complication. There was a 14.1% (26/185) mortality at a median of 2.5 years (IQR 4.9). 51(29%) had complications during the interstage period, most common being recurrence of infection requiring a spacer exchange (48.6%). 2 patients died and 2 patients failed to progress to the second stage. 22(12%) complications following re-implantation, most commonly persistence /recurrence of infection (31%). 183/185 patients that initiated a two stage exchange were re-implanted, only 65% (120/185) were successfully treated with or without antibiotic suppression at one-year without additional surgery. Conclusions. While 2 stage exchanges for PJI in THA have been reported as successful, there are few reports of the complications during the process. In our series, significant numbers of patients experienced complications, often during the interstage period, highlighting the morbidity of this method of treatment

Aims. Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNFs), especially in physiologically younger patients. While THA for osteoarthritis (OA) has demonstrated low complication rates and increased quality of life, results of THA for acute FNF are not as clear. Currently, a THA performed for FNF is included in an institutional arthroplasty bundle without adequate risk adjustment, potentially placing centres participating in fracture care at financial disadvantage. The purpose of this study is to report on perioperative complication rates after THA for FNF compared with elective THA performed for OA of the hip. Patients and Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2008 and 2016 was queried. Patients were identified using the THA Current Procedural Terminology (CPT) code and divided into groups by diagnosis: OA in one and FNF in another. Univariate statistics were performed. Continuous variables were compared between groups using Student’s t-test, and the chi-squared test was used to compare categorical variables. Multivariate and propensity-matched logistic regression analyses were performed to control for risk factors of interest. Results. Analyses included 139 635 patients undergoing THA. OA was the indication in 135 013 cases and FNF in 4622 cases. After propensity matching, mortality within 30 days (1.8% vs 0.3%; p < 0.001) and major morbidity (24.2% vs 19%; p < 0.001) were significantly higher among FNF patients. Re-operation (3.7% vs 2.7%; p = 0.014) and re-admission (7.3% vs 5.5%; p = 0.002) were significantly higher among FNF patients. Hip fracture patients had significantly longer operative time and length of stay (LOS), and were significantly less likely to be discharged to their home. Multivariate analyses gave similar results. Conclusion. This large database study showed a higher risk of postoperative complications including mortality, major morbidity, re-operation, re-admission, prolonged operative time, increased LOS, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. While THA is a good option for FNF patients, there are increased costs and financial risks to centres with a joint arthroplasty bundle programme participating in fracture care. Cite this article: Bone Joint J 2019;101-B(6 Supple B):84–90

Total hip replacement (THR) for end-stage osteoarthritis is a commonly performed cost-effective procedure, which provides patients with significant clinical improvement. Estimating the future demand for joint replacement is important to identify the healthcare resources needed. We estimated the number of primary THRs that will need to be performed up to the year 2060. We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the current volume of primary THR (n=94,936) performed in 2018. We projected future numbers of THR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060. By 2060, primary THR volume would increase from 2018 levels by an estimated 37.7% (n=130,766). For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70–79 years (144.6% males, 141.2% females); 80–89 years (212.4% males, 185.6% females); 90 years and older (448.0% males, 298.2% females). By 2060 demand for THR is estimated to increase by almost 40%. Demand will be greatest in older patients (70 years+), which will have significant implications for the health service that requires forward planning given morbidity and resource use is higher in this population. There is a backlog of current demand with cancellation of elective surgery due to seasonal flu pressures in 2017 and now Covid-19 in 2020. Orthopaedics already has the largest waiting list of any speciality. These issues will negatively impact the health services ability to deliver timely joint replacement to many patients for a number of years and require urgent planning

Hip fractures in elderly patients are managed at both major trauma centers (MTC) and trauma units (TU). Previous evidence has demonstrated the importance of early surgery to reduce the morbidity and mortality related to the injury. The aim of this study is to compare the ‘time to theatre' and ‘30 day mortality' in TUs versus MTC in UK. A retrospective review of prospectively collected data on NHFD was performed. The average ‘time to theatre' in hours and ‘30 day mortality' of all hospitals were analysed between January and December 2018. Further subgroup analysis was done to check for any regional variations; in each instance a Shapiro-Wilk test was used to check for normal distribution, followed by a one-way ANOVA with a Tukey's post hoc test. Data from 158 hospitals in England (ENG), Wales (WAL) and Northern Ireland (NI) were used; 18 of which were MTC. There were 57,936 operative cases in TUs and 8606 in MTC's. The mean time (hours) to surgery from presentation was 32.51 and 32.64 for TUs and MTC respectively (p=0.513). There was no significant difference in ‘30 day mortality' (p=0.635) between TUs (6%) and 5.7% MTC's (5.7%), MTC's and TUs in ENG, WAL and NI (p=0.555), and MTC and WAL, NI and the different regions of ENG (p=0.209). A significant difference was observed, between the regional practice for TUs versus MTC's in ENG, WAL and NI (p=0.001) and between MTC's and TUs in WAL, NI and the different regions of ENG (p=0.001), with patients waiting significantly longer in NI for their procedure (mean=60.25 hours, p=0.001). There was no significant difference in time to surgery or 30 day mortality between TUs and MTC's, demonstrating comparable hip fracture care, despite MTCs need to prioritise more serious injuries

Aims. Hip fracture patients have high morbidity and mortality. Patient-reported outcome measures (PROMs) assess the quality of care of patients with hip fracture, including those with chronic cognitive impairment (CCI). Our aim was to compare PROMs from hip fracture patients with and without CCI, using the Norwegian Hip Fracture Register (NHFR). Methods. PROM questionnaires at four months (n = 34,675) and 12 months (n = 24,510) after a hip fracture reported from 2005 to 2018 were analyzed. Pre-injury score was reported in the four-month questionnaire. The questionnaires included the EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, and information about who completed the questionnaire. Results. Of the 34,675 included patients, 5,643 (16%) had CCI. Patients with CCI were older (85 years vs 81 years) (p < 0.001), and had a higher American Society of Anesthesiologists (ASA) classification compared to patients without CCI. CCI was unrelated to fracture type and treatment method. EQ-5D index scores were lower in patients with CCI after four months (0.37 vs 0.60; p < 0.001) and 12 months (0.39 vs 0.64; p < 0.001). Patients with CCI had lower scores for all dimensions of the EQ-5D-3L pre-fracture and at four and 12 months. Conclusion. Patients with CCI reported lower health-related quality of life pre-fracture, at four and 12 months after the hip fracture. PROM data from hip fracture patients with CCI are valuable in the assessment of treatment. Patients with CCI should be included in future studies. Cite this article: Bone Jt Open 2021;2(7):454–465