Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing.

£250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics.

11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort.

Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort.

Aims. To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods. We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results. In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion. The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. Cite this article: Bone Jt Open 2023;4(9):652–658

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

Background. Orthopaedic surgeons are exposed to high levels of noise when performing common surgical procedures. Noise induced hearing loss (NIHL) has been demonstrated amongst senior orthopaedic staff. The objective of this study was to investigate the prevalence of hearing loss amongst arthroplasty surgeons compared to non-surgical clinicians and explore the factors associated with hearing loss. Methods. A cross-sectional prevalence study. Arthroplasty surgeons and non-surgical clinicians were recruited from orthopaedic and medical conferences. All participants were given a paper questionnaire including demographic details, hearing history and Tinnitus and Hearing Survey (THS). All participants were screened for hearing loss in a quiet room using the HearCheck Screener™ (Siemens, UK). Logistic regression was used to identify factors associated with hearing loss. All statistical models were adjusted for age, gender, smoking status and personal noise exposure. A power calculation estimated a sample size of 100 participants. Results. The HEARS study recruited 189 participants (107 arthroplasty surgeons; 82 non-surgical clinicians). Prevalence of hearing loss identified by the HearCheck Screener™; 31% arthroplasty surgeons vs 11% non-surgical clinicians. The odds of failing the HearCheck Screener™ were 3.7 times higher in arthroplasty surgeons compared to their non-surgical colleagues (p<0.004). Similarly, the odds of self-reported hearing loss were 2.79 times higher amongst arthroplasty surgeons (p<0.003). Conclusion. The prevalence of hearing loss amongst arthroplasty surgeons is significantly higher than their non-surgical colleagues. Noise generated during arthroplasty surgery should be recognised and managed to create safer working conditions

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems

Proximal hamstring tendon avulsion from the ischial tuberosity is a significant injury, with surgical repair shown to have superior functional outcomes compared to non-surgical treatment. However, limited data exists regarding the optimal rehabilitation regime following surgical repair. The aim of this study was to investigate patient outcomes following repair of proximal hamstring tendon avulsions between a conservative (CR) versus an accelerated rehabilitation (AR) regimen. This prospective randomized controlled trial (RCT) randomised 50 patients undergoing proximal hamstring tendon repair to either a braced, partial weight-bearing rehabilitation regime (CR=25) or an accelerated, unbraced regime, that permitted full weight-bearing as tolerated (AR=25). Patients were evaluated pre-operatively and at 3 and 6 months post-surgery, via patient-reported outcome measures (PROMs) including the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT) and 12-item Short Form Health Survey (SF-12). Primary analysis was per protocol and based on linear mixed models. Both groups were matched at baseline with respect to patient characteristics. All PROMs improved (p>0.05) and, while the AR group reported a significantly better Physical Component Score for the SF-12 at 3 months (p=0.022), there were no other group differences. Peak isometric hamstrings strength and peak isokinetic quadriceps and hamstrings torque symmetry were all comparable between groups (p>0.05). Three re-injuries have been observed (CR=2, AR=1). After proximal hamstring repair surgery, post-operative outcomes following an accelerated rehabilitation regimen demonstrate comparable outcomes to a traditionally conservative rehabilitation pathway, albeit demonstrating better early physical health-related quality of life scores, without an increased incidence of early re-injury

To date there is no medical treatment alternative to surgery for osteolysis after THA. In this proof-of-concept clinical trial we examined the effect of a human monoclonal antibody against osteoclasts versus placebo on osteolytic lesion activity in patients undergoing revision surgery. Patients scheduled for revision for symptomatic osteolysis were randomised (1:1) to receive either denosumab 60mg or placebo subcutaneously eight weeks prior to operation. At surgery, biopsies from the osteolytic membrane-bone interface were taken for histomorphometric analysis of osteoclast number. Secondary outcome measures included systemic bone turnover markers. 22 subjects completed the study (10 denosumab). The denosumab group had 83% (−63 to −97), P=0.011 fewer osteoclasts at osteolytic lesion sites, 87% lower osteoclast surface (−65 to −95, P=0.009), and 72% lower eroded surface (−35 to −93, P=0.020) versus the placebo group. At surgery, serum CTX-I, TRAP5b and PINP were 80% (−65 to −95, p<0.001), 57% (−40 to −90, p<0.001), and 44% (−41 to −65, p<0.001) lower in the denosumab versus placebo groups, respectively. The rate of adverse events (denosumab 6, placebo 7) were similar between groups (P>0.05). These data provide a biological basis for a definitive clinical trial using pain, function and prosthesis survival as the study endpoints. As osteolysis/ aseptic loosening is the leading cause of prosthesis failure world-wide, the establishment of a non-surgical solution would reduce patient suffering and dramatically reducing the cost to healthcare economies

Aims. Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. Methods. A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. Results. In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). Conclusion. This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305–308

Background. Delay in access to primary total hip (THA) arthroplasty continues to pose a substantial burden to patients and society in publicly funded healthcare systems. The majority of strategies to decrease wait times have focused on the time from surgical consult to surgery, however a large proportion of total wait time for these patients is the time from primary care referral to surgical consultation. Prioritization scoring tools and patient reported outcome measures are being used in an attempt to ration limited resources in the face of increasing demand. However, to our knowledge, no study has investigated whether a referral Oxford Hip Score (OHS) could be used to triage non-surgical referrals appropriately, in an effort to increase timely access to specialists for patients that are candidates for total joint replacement (TJR). Purpose. 1) To determine if a referral OHS has the predictive ability to discriminate when a hip patient will be deemed surgical versus conservative by the surgeon during their first consultation 2) To identify an OHS cut-off point that can be used to accurately predict when a primary THA referral will be deemed conservative by the consultant surgeon during the first consultation. Methods. We retrospectively reviewed all consecutive THA consultations from a single surgeon's tertiary, high volume practice over a 3-year period. Patients with a pre-consultation OHS, BMI <41, and no absolute contraindication to TJR were included. Consultation were categorized into two groups based on surgeon's decision, those that were offered THR during their first consultation (operative) versus those that were not (conservative). Baseline demographic data and OHS were abstracted. Variables of interest were compared between cohorts using the exact chi-square test and Wilcoxon rank-sum test. Spearman's rank correlation coefficients were used to measure association between pre-consult OHS and the surgeon's decision. A receiver operator characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) and to identify a cut-off point for the pre-operative OHS that identified whether or not a referral was deemed conservative. Results. The study 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p<0.001). Spearman's rank correlation coefficient between OHS and a patient being deemed surgical or conservative was strong for the OHS at −0.62 (95% CI −0.67 to −0.56). The ROC AUC values for hip consults (0.87, 95% CI 0.84–0.91) was good, indicating that pre-consult OHS has predictive ability to discriminate a surgeon's decision of surgical versus conservative. One plausible conservative threshold that optimized sensitivity and NPV for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower, depending on weight of prioritization of sensitivity, specificity, and NPV. Conclusion. Referral OHS demonstrate good ability to discriminate when a knee or hip TJR referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential OHS thresholds can be applied as a tool to decrease wait times for primary THR. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be validated with multi-surgeon/center studies before they can be broadly applied

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

Aims

In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance.

Aims

Pelvic tilt is believed to affect the symptomology of osteoarthritis (OA) of the hip by alterations in joint movement, dysplasia of the hip by modification of acetabular cover, and femoroacetabular impingement by influencing the impingement-free range of motion. While the apparent role of pelvic tilt in hip pathology has been reported, the exact effects of many forms of treatment on pelvic tilt are unknown. The primary aim of this study was to investigate the effects of surgery on pelvic tilt in these three groups of patients.

Aims

The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs).

Aims

The aim of this study was to assess medium-term improvements following total hip arthroplasty (THA), and to evaluate what effect different preoperative Oxford Hip Score (OHS) thresholds for treatment may have on patients’ access to THA and outcomes.

Aims

The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

There is a paucity of available literature to guide the surgeon treating postoperative fractures of the greater trochanter after femoral component revision. Between 2009 and 2016, 133 patients underwent femoral component revision by the senior author utilizing a modular tapered fluted titanium stem. 17 patients died or had inadequate follow-up. Therefore, 116 patients were included in the final analysis. There were 58 males and 58 females with a mean age of 64 (range 23 to 91 years old). Clinical and radiographic data were analyzed for postoperative greater trochanteric fracture (GTfx). Mean clinical follow up was 21 months (range 3 to 77 mos). Age, BMI, preoperative diagnosis, comorbidities, reason for revision, use of Extended Trochanteric Osteotomy (ETO), fixation method of ETO, presence of prior hardware, post-operative trauma (falls), femoral component size and offset, change in leg length were analyzed to determine potential risk factors for postoperative GT fracture. There were 7 postoperative greater trochanteric fractures in 7 patients (6%). Of these, 1 occurred as a result of a postoperative fall, 1 occurred after dislocation, and 1 occurred after a fall with a subsequent dislocation. The mean time to diagnosis of the fracture was 10.7 weeks postoperatively (range one day to 37.4 weeks). 52 of 116 patients had their revision performed through an ETO. Of those, 6 had a postoperative fracture of the GT. The use of an ETO significantly increased the likelihood of postoperative GT fx (p=0.035). Regarding femoral component size, use of a longer proximal body (+10 or greater) was associated with an increased risk of postoperative GT fx (p=0.07). Two fractures were minimally (<1cm) or non-displaced and were treated non-operatively. Of these fractures, 1 united. The other fracture further displaced and resulted in recurrent instability. This was treated with excision of the fragment and a constrained liner. 5 fractures were displaced and were treated with ORIF. 3 were fixed with a cable grip device, 1 was plated, and 1 was treated with a cable grip device and a constrained liner. Of those treated with some form of ORIF, all 5 healed. Of those that underwent surgical fixation initially, 3 reported residual trochanteric pain and 1 patient had their hardware removed (trochanteric claw). 2 of these patients have a residual limp and require a cane for use as a gait aid. The patient treated non-surgically required a cane as did the patient that failed non-surgical treatment. Post-operative greater trochanteric fractures are a rare complication of femoral component revision. The use of an ETO significantly increased the rate of post of GTfx. The mean time to diagnosis of was 11 weeks. Displaced fractures of the greater trochanter treated with ORIF all healed, both cable grip devices and plates were effective. Residual limp requiring gait aids and residual trochanteric pain were common outcomes after fixation of these fractures despite successful union

Aims

Aseptic loosening is a leading cause of uncemented arthroplasty failure, often accompanied by fibrotic tissue at the bone-implant interface. A biological target, neutrophil extracellular traps (NETs), was investigated as a crucial connection between the innate immune system’s response to injury, fibrotic tissue development, and proper bone healing. Prevalence of NETs in peri-implant fibrotic tissue from aseptic loosening patients was assessed. A murine model of osseointegration failure was used to test the hypothesis that inhibition (through Pad4^-/- mice that display defects in peptidyl arginine deiminase 4 (PAD4), an essential protein required for NETs) or resolution (via DNase 1 treatment, an enzyme that degrades the cytotoxic DNA matrix) of NETs can prevent osseointegration failure and formation of peri-implant fibrotic tissue.

Aims

The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version?