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

Increased collection of patient-reported outcome measures (PROM) in registries enables international comparison of patient-centered outcomes after knee and hip replacement. We aimed to investigate 1) variations in PROM improvement, 2) the possible confounding factor of BMI, and 3) differences in comorbidity distributions between registries. Registries affiliated with the International Society of Arthroplasty Registries (ISAR) or OECD membership countries were invited to report aggregate EQ-5D, OKS, OHS, HOOS-PS and KOOS-PS values. Eligible patients underwent primary total, unilateral knee or hip replacement for osteoarthritis within three years and had completed PROMs preoperatively and either 6 or 12 months postoperatively, excluding patients with subsequent revisions. For each PROM cohort, Chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (male/female, age 20-64/65-74/>75, high or low preoperative PROM scores). Comorbidity distributions were reported for available comorbidity indexes. Thirteen registries from 9 countries contributed data, n~130000 knee (range 140 to 79848) and n~113000 hip (range 137 to 85281). Mean EQ-5D index values (10 registries) ranged from 0.53 to 0.71 (knee) and 0.50 to 0.70 (hips) preoperatively and 0.78 to 0.85 (knee) and 0.83 to 0.87 (hip) postoperatively. Mean OKS (6 registries) ranged from 19.3 to 23.6 preoperatively and 36.2 to 41.2 postoperatively. Mean OHS (7 registries) ranged from 18.0 to 23.2 preoperatively and 39.8 to 44.2 postoperatively. Four registries reported KOOS-PS and three reported HOOS-PS. Proportions of patients with BMI >30 ranged from 35 to 62% (10 knee registries) and 16 to 43% (11 hip registries). For both knee and hip registries, distributions of patients across six BMI categories differed significantly among registries (p30 were for patients in the youngest age groups (20 to 64 and 65 to 74 years) with the lowest baseline scores. Additionally, females with lowest preoperative PROM scores had highest BMI. These findings were echoed for the OHS and OKS cohorts. Proportions of patients with ASA scores ≥3 ranged from 7 to 42% (9 knee registries) and 6 to 35% (8 hip registries). PROM-score improvement varies between international registries, which may be partially explained by differences in age, sex and preoperative scores. BMI and comorbidity may be relevant to adjust for

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Hip resurfacing arthroplasty (HRA) is a bone conserving alternative to total hip arthroplasty. We present the early 1 and 2-year clinical and radiographical follow-up of a novel ceramic-on-ceramic (CoC) HRA in a multi-centric Australian cohort. Patient undergoing HRA between September 2018 and April 2021 were prospectively included. Patient-reported outcome measures (PROMS) in the form of the Forgotten Joint Score (FJS), HOOS Jr, WOMAC, Oxford Hip Score (OHS) and UCLA Activity Score were collected preoperatively and at 1- and 2-years post-operation. Serial radiographs were assessed for migration, component alignment, evidence of osteolysis/loosening and heterotopic ossification formation. 209 patients were identified of which 106 reached 2-year follow-up. Of these, 187 completed PROMS at 1 year and 90 at 2 years. There was significant improvement in HOOS (p< 0.001) and OHS (p< 0.001) between the pre-operative, 1-year and 2-years outcomes. Patients also reported improved pain (p<0.001), function (p<0.001) and reduced stiffness (p<0.001) as measured by the WOMAC score. Patients had improved activity scores on the UCLA Active Score (p<0.001) with 53% reporting return to impact activity at 2 years. FJS at 1 and 2-years were not significantly different (p=0.38). There was no migration, osteolysis or loosening of any of the implants. The mean acetabular cup inclination angle was 41.3° and the femoral component shaft angle was 137°. No fractures were reported over the 2-year follow-up with only 1 patient reporting a sciatic nerve palsy. There was early return to impact activities in more than half our patients at 2 years with no early clinical or radiological complications related to the implant. Longer term follow-up with increased patient numbers are required to restore surgeon confidence in HRA and expand the use of this novel product. In conclusion, CoC resurfacing at 2-years post-operation demonstrate promising results with satisfactory outcomes in all recorded PROMS

The prevalence of gluteal tendinopathy (GT) associated with osteoarthritis of the hip is difficult to determine as it is frequently undiagnosed or misdiagnosed as trochanteric bursitis. Its relationship to total hip arthroplasty (THA) outcomes is currently unknown. The aim of this study was to determine the incidence of GT at the time of hip arthroplasty and examine the relationship between GT and patient reported outcomes (PROMS) before and after THA. Patients undergoing THA for primary osteoarthritis between August 2017 and August 2020 were recruited. Tendinopathy was assessed and graded at time of surgery. PROMS included the Oxford Hip Score (OHS), HOOS JR, EQ-5D, and were collected preoperatively and at one year after THA. Satisfaction with surgery was also assessed at 1 year. 797 patients met eligibility criteria and were graded as Grade 1: normal tendons (n =496, 62%), Grade 2: gluteal tendinopathy but no tear (n=222, 28%), Grade 3: partial/full thickness tears or bare trochanter (n=79, 10%). Patients with abnormal gluteal tendons were older (p=0.001), had a higher mean BMI (p=0.01), and were predominately female (p=0.001). Patients with higher grade tendinopathy had statistically significant inferior PROMS at one year, OHS score (44.1 v 42.9 v 41.3, p 0.001) HOOS JR (89.3 V 86.3 V 85.6 p 0.005). Increasing gluteal tendon grade was associated with a greater incidence of problems with mobility (p=0.001), usual activities (p=0.001) and pain (p=0.021) on EQ5D. There was a 3 times relative risk of overall dissatisfaction with THA in the presence of gluteal tears. This study demonstrated that gluteal tendinopathy was commonly observed and associated with inferior 1-year PROMS in patients undergoing THA for OA. Increasing degree of tendinopathy was a negative prognostic factor for worse functional outcomes and patient satisfaction

A large proportion of wait times for primary total knee (TKA) and hip (THA) arthroplasty is the time from primary care referral to surgical consultation. To our knowledge, no study has investigated whether a referral Oxford Knee or Hip Score (OKHS) could be used to triage non-surgical referrals appropriately. The primary purpose of the current study was to determine if a referral OKHS has the predictive ability to discriminate when a knee or hip referral will be deemed conservative as compared to surgical by the surgeon during their first consultation, and to identify an OKHS cut-off point that accurately predicts when a primary TKA or THA referral will be deemed conservative. We retrospectively reviewed all consecutive primary TKA and THA consultations from a single surgeon's tertiary, high volume practice over a three-year period. Patients with a pre-consultation OKHS, BMI < 4 1, and no absolute contraindication to TJR were included. Consultation knees/hips were categorized into two groups based on surgeon's decision, those that were offered TJR during their first consolation (surgical) versus those that were not (conservative). Baseline demographic data and OKHS 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 OKHS 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 OKHS that identified whether or not a referral was deemed conservative. TKA and THA referrals were analyzed separately. The study included 1,436 knees (1,016 patients) with a median OKS of 25 (IQR 19–32) and 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OKHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p 32 (sensitivity=0.997, NPV=0.992) and for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower OKHS thresholds, depending on weight of prioritization of sensitivity, specificity, and NPV. Referral OKS and OHS demonstrate good ability to discriminate when a primary TKA or THA referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential effective OKHS thresholds can be applied as a tool to decrease wait times for primary joint arthroplasty. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be externally validated before they can be broadly applied

Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the Duplex. TM. implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection

Adverse spinopelvic characteristics (ASC) have been associated with increased dislocation risk following primary total hip arthroplasty (THA). A stiff lumbar spine, a large posterior standing tilt when standing and severe sagittal spinal deformity have been identified as key risk factors for instability. It has been reported that the rate of dislocation in patients with such ASC may be increased and some authors have recommended the use of dual mobility bearings or robotics to reduce instability to within acceptable rates (<2%). The aims of the prospective study were to 1: Describe the true incidence of ASC in patients presenting for a THA 2. Assess whether such characteristics are associated with greater symptoms pre-THA due to the concomitant dual pathology of hip and spine and 3. Describe the early term dislocation rate with the use of ≤36mm bearings. This is an IRB-approved, two-center, multi-surgeon, prospective, consecutive, cohort study of 220 patients undergoing THA through anterolateral- (n=103; 46.8%), direct anterior- (n=104; 27.3%) or posterior- approaches (n=13; 5.9%). The mean age was 63.8±12.0 years (range: 27.7-89.0 years) and the mean BMI 28.0±5.0 kg/m. 2. (range: 19.4-44.4 kg/m. 2. ). There were 44 males (47.8%) and 48 females (52.2%). The mean follow-up was 1.6±0.5 years. Overall, 54% of femoral heads was 32 mm, and 46% was 36mm. All participants underwent lateral spinopelvic radiographs in the standing and deep-flexed seated positions were taken to determine lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA) and pelvic incidence (PI) in both positions. Spinal stiffness was defined as lumbar flexion <20° when transitioning between the standing and deep-seated position; adverse standing PT was defined as >19° and adverse sagittal lumbar balance was defined as mismatch between standing PI and LL >10°. Pre-operative patient reported outcomes was measured using the Oxford Hip Score (OHS) and EuroQol Five-Dimension questionnaire (EQ-5D). Dislocation rates were prospectively recorded. Non-parametric tests were used, significance was set at p<0.05. The prevalence of PI-LL mismatch was 22.1% (43/195) and 30.4% had increased standing PT (59/194). The prevalence of lumbar stiffness was 3.5% (5/142) and these patients had all three adverse spinopelvic characteristics (5/142; 3.5%). There was no significant difference in the pre-operative OHS between patients with (20.7±7.6) and patients without adverse spinopelvic characteristics (21.6±8.7; p=0.721), nor was there for pre-operative EQ5D (0.651±0.081 vs. 0.563±0.190; p=0.295). Two patients sustained a dislocation (0.9%): One in the lateral (no ASC) and one in the posterior approaches, who also exhibited ASC pre-operatively. Sagittal lumbar imbalance, increased standing spinal tilt and spinal stiffness are not uncommon among patients undergoing THA. The presence of such characteristics is not associated with inferior pre-operative PROMs. However, when all characteristics are present, the risk of instability is increased. Patients with ASC treated with posterior approach THA may benefit from the use of advanced technology due to a high risk of dislocation. The use of such technology with the anterior or lateral approach to improve instability is to date unjustified as the rate of instability is low even amongst patients with ASCs

Aim. The aim of this study is to evaluate if obesity negatively affects: (1) complication rate, (2) reoperation and revision rate and (3) functional outcome (based on patient reported outcome measures, PROMs) in revision total hip arthroplasty (rTHA). To our knowledge this is the only recent study to prospectively review these three aspects in what might be considered challenging rTHA. Methods. 444 rTHAs (cup, stem, both, n= 265, 57, 122 respectively), performed in a specialized high-volume orthopaedic center from 2013 to 2015, were prospectively followed. Complications and Oxford Hip Score (OHS) were evaluated at 4 months, 1 year and 2 years. Thirtyfour patients had a BMI >35 kg/m2 (obese), of which thirteen patients with a BMI >40 kg/m2 (morbidly obese). Results. Infection following rTHA was more common in obese patients (8/34: 24%) and in morbidly obese patients (5/13: 38%) than in non-obese patients (15/410: 4%; p's < 0.001). No differences between obese and non-obese groups for other complications were observed (aseptic loosening, dislocation, periprosthetic fractures, thromboembolic events). Reoperation and revision rates were similar overall (p = 0.067 / 0.303 respectively) and due to infection (p = 0.469 / 0.879 respectively) for obese and non-obese groups. Scores on the OHS improved from 42 ±13 at baseline to 27±12 at 1 and 2 year follow-up (p < 0.001). Obese patients had overall poorer OHS scores than non-obese patients (p < 0.001), but improvement of OHS did not differ between obese and non-obese patients (p = 0.198). Conclusion. Obesity is associated with an increased risk of infection following revision THA. Patients with high BMI should be counselled appropriately before surgery

Aims. Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. Materials and Methods. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome. Results. 180 revisions in 163 patients were identified at a median follow-up of 5.48 (2–11.7) years. There were 152 (84.4%) in the symptomatic subgroup and 28 (15.6%) in the asymptomatic group. Overall median OHS improved from 29 to 37 with revision (P<0.001). Symptomatic patients experienced greater functional benefit (DOHS 6.5 vs. 1.4, p=0.012) compared to asymptomatic patients, though they continued to report inferior outcomes (OHS 36.5 vs 43, p=0.004). The functional outcome of asymptomatic patients was unaffected by revision surgery (pre-revision OHS 41, post-revision OHS 43, p=0.4). Linear regression analysis confirmed use of a cobalt-chrome (CoCr)-containing bearing surface (MoM or metal-on- polyethylene) at revision and increasing BMI were predictive of poor functional outcome (R. 2. 0.032, p=0.0224 and R. 2. 0.039, p=0.015 respectively). Pre- and post-revision serum metal ions and pre-revision MRI findings were not predictive of outcome. The overall complication rate was 36% (n=65) with a re-revision rate of 6.7%. The most common complication was ongoing adverse reaction to metal debris (ARMD, defined as positive post-revision MRI) in 21.1%. The incidence of ongoing ARMD was not significantly different between those with CoCr reimplanted and those without (p=0.12). Conclusions. To our knowledge, our study represents the largest single-centre consecutive series of revision THRs from MoM bearings in the literature. Symptomatic patients experience the greatest functional benefit from revision surgery but do not regain the same level of function as patients who were asymptomatic prior to revision. The re-implantation of CoCr as a primary bearing surface and increasing BMI was associated with poorer functional outcome

INTRODUCTION. Wedge femoral stems used in total hip arthroplasty (THA) have evolved with modifications including shorter lengths, reduced distal geometries, and modular necks. Unlike fit and fill stems which contact most of the metaphysis, tapered wedge femoral stems are designed to achieve proximal medial/lateral fixation. These single taper, wedge stems have demonstrated positive clinical outcomes. The tapered wedge stem evaluated in this study has further reduced distal geometry to provide a wedge-fit within the metaphysis of the proximal femoral canal for all femur types (Dorr A, B, C). The objective of this study was to evaluate the early clinical outcomes, including femoral stem subsidence, of a tapered wedge femoral stem. METHODS. Fifty subjects (28 males, 22 females; mean age: 64.7±9.7 years; mean BMI: 29.6±4.6) underwent primary THA with a tapered wedge femoral stem. IRB approval was received prior to conducting the study and all participants signed the informed consent. Clinical data outcomes for this study included the Harris Hip Score (HHS), the Oxford Hip Score (OHS), revisions, and subsidence at the 6-week, 3-month, 1-year, and 2-year post-operative time points. Femoral stem subsidence was measured by an independent third party. Student t-tests were used to identify significant mean differences between genders (p<0.05). RESULTS. For patients returning for their 2-year post- operative visit (n=42), the HHS improved by 40.7 points to 91.9 from 51.2 and the OHS improved by 23.5 points to 44.6 from 21.1. There was no significant difference between genders with regard to age, BMI, or HHS scores. However, the males had significantly higher pre-operative OHS scores (23.4 vs. 18.2) and 3-month post-operative OHS scores (43.7 vs. 40.3). There were no revisions. There were no observations of femoral stem subsidence at 1 year (n=45) or 2 years (n=40). DISCUSSION. The tapered wedge femoral stem exhibited positive early clinical results as demonstrated by the significant improvement in functional outcome scores from the pre-operative visit to 2-years post-operative. These 2-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Functional outcomes scores continued to improve at the 6-week, 3-month, and 1-year post-operative visits. The 1-year and 2-year outcomes were not significantly different. Additionally, the implant was well fixated as there were no reports of femoral stem subsidence 2 years post-operative. SIGNIFICANCE. The tapered wedge femoral stem evaluated in this study demonstrated positive early clinical performance with no reports of femoral stem subsidence or revisions. This tapered wedge stem design is a promising alternative to conventional femoral stems

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

INTRODUCTION. Additive manufacturing (3D printing) is used to create porous surfaces that promote bone ingrowth in an effort to improve initial stability and optimize long-term biological fixation. The acetabular cup that was studied is manufactured with titanium alloy powder via electron beam melting. Electron beam melting integrates the porous and solid substrate rather than sintering a porous coating to a solid surface. The 3D-printed acetabular cup's high surface coefficient of friction (up to 1.2), combined with its geometry, creates a predictable press-fit in the acetabulum, improving initial mechanical stability and ultimately leading to reproducible biologic fixation. The objective of this study was to evaluate the early clinical outcomes and implant fixation of this 3D-printed acetabular cup in total hip arthroplasty (THA). METHODS. Four hundred twenty-eight subjects from 8 US and international research sites underwent primary THA with the 3D-printed acetabular cup. All sites received IRB approval prior to conducting the study, and all participants signed the informed consent. Screw usage and number used during surgery were used as a surrogate measurement for initial implant fixation. Clinical performance outcomes included pre- and post-operative Harris Hip Scores (HHS) and Oxford Hip Scores (OHS), patient satisfaction, and revision assessment. 215 patients had a minimum 1-year post-operative follow-up visit. Student t-tests were used to identify significant mean differences (p<0.05). RESULTS. Acetabular screws were used in 206 of 428 cases (48.1%); 85.9% used 1 screw, 12.6% used 2 screws, and 1.5% used 3 screws. For patients with a 1-year post-operative visit, the HHS improved by 49.8 points to 91.9 from 42.1, and the OHS improved by 27.7 points to 44.4 from16.7. Patient satisfaction scores at the 1-year post-operative visit were 9.7±0.7 (n=94). There was no significant difference between genders with regard to BMI, the 1-year post-operative HHS, OHS, or patient satisfaction scores. However, the males were significantly younger (59.8 vs. 62.9 years) and had significantly higher pre-operative HHS (45.7 vs. 37.9) and OHS scores (17.8 vs. 15.3). There were 9 revisions reported. DISCUSSION. For initial implant fixation, compared to a similar, non-3D-printed acetabular cup in the same product line, the 3D-printed cup used significantly fewer screws per case (n=1 for 85.9% cases vs. n=2 for 85.7% of cases) in a fewer percentage of cases (48.1% vs. 70.4%), suggesting greater initial stability and “scratch fit”. The 3D-printed acetabular cup also displayed positive early clinical results as evidenced by the pronounced improvement in clinical outcome scores from the pre-operative visit to the 1-year post-operative visit. These 1-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Patient satisfaction scores were also excellent (9.7/10). There were nine revisions; however, four of these were due to patient falls and one was due to infection. SIGNIFICANCE. The 3D-printed acetabular cup evaluated in this study demonstrated improved implant fixation and positive early clinical outcomes for THA

Introduction. Instability accounts for one third of revision total hip arthroplasty(rTHA) performed in the United Kingdom. Removal of well-fixed femoral stems in rTHA is challenging with a risk of blood loss and iatrogenic damage to the femur. The Bioball Universal Adaptor (BUA) (Merete, Germany), a modular head neck extension adaptor, provides a mechanism for optimisation of femoral offset, leg length and femoral anteversion. This can avoid the need for femoral stem revision in selected cases. There is a relative paucity of clinical data available with the use of this device. Aim. The aim of this study is to present the clinical results and rate of instability following revision with this head neck adaptor at a minimum of two years' follow up. Patients and Methods. A review of our prospectively collected database was performed. All patients treated with the Bioball device were included. Clinical and radiologic review were performed pre- and post-surgery. Specific enquiry for instability was made. The Oxford Hip Score (OHS), Euro-Quol (EQ-5D) score and WOMAC scores were calculated pre-and post-operatively. Complications were recorded. Statistical analysis using a Students t-test with a significance level of p<0.05 was considered to be statistically significant. Results. Thirty-two rTHA procedures were performed using the Bioball device between 2013 and 2016. Four patients did not wish to complete post-operative questionnaires. These had no complaints regarding their revised hips and were functioning well. Two patients (2/28, 7%) complained of recurrent dislocations following their rTHA procedure. One patient complained of instability but no dislocation. The median pre-operative EQ-5D was 0.195 (range −0.07 to 0.85), OHS was 20 (range 5 to 43) and WOMAC was 29.8 (range 15.5 to 52.3). The median EQ-5D was 0.85 (range 0.59 to 1), OHS was 39 (range 21 to 48) and WOMAC was 91.1 (range 44.5 to 99.2) at final follow up. There were significant improvements in the EQ-5D (p = 0.0009), OHS (p = 0.0004) and WOMAC (p = 0.0001). Conclusion. The Bioball Head Neck Adaptor is associated with significant functional improvement and relatively low dislocation rates in revision THA. It is a viable option for use in the revision setting

Aim. To assess the influence of route of antibiotic administration on patient-reported outcome measures (PROMS) of individuals treated for hip and knee infections in the OVIVA multi-centre randomised controlled trial. Method. This study was designed to determine whether oral antibiotic therapy is non-inferior to intravenous (IV) therapy when given for the first six weeks of treatment for bone and joint infections. Of the 1054 participants recruited from 26 centres, 462 were treated for periprosthetic or native joint infections of the hip or knee. There were 243 participants in the IV antibiotic cohort and 219 in the oral cohort. Functional outcome was determined at baseline through to one year using the Oxford Hip/Knee Score (OHS/OKS) as joint-specific measures (0 the worse and 48 the best). An adjusted quantile regression model was used to compare functional outcome scores. Results. Of the 214 participants in the hip sub-group, 110 were randomized to IV antibiotics and 104 to oral. Of the 248 participants in the knee cohort, 133 were treated with IV antibiotics and 115 with oral. The OHS/OKS questionnaire response rate was 68%. Baseline median OHS of the hip sub-group was 14 (Interquartile range [IQR]:8–22) for the IV cohort and 12 (IQR:7–22) for the oral cohort. The one-year median OHS was 35 (IQR: 23–44) for the IV cohort and 27 (IQR:16–40) for the oral cohort with no significant difference between cohorts (p=0.181). The baseline median OKS of the knee sub-group, was 14 (IQR:8–23) for the IV cohort and 12 (IQR:8–21) for the oral cohort. The one-year median OKS was 24 (IQR: 15–35) for the IV cohort and 27 (IQR:17–38) for the oral cohort with a statistically significant difference in favour of oral therapy (p=0.036). Conclusions. At one year, there was improvement in functional outcome of patients treated with either IV or oral antibiotics in this RCT. It suggests that joint function generally improved progressively following the start of treatment irrespective of the route of antibiotic therapy. Functional outcome of patients with hip infections was similar irrespective of the route of antibiotic therapy, whereas there was statistically greater improvement in functional outcome of patients with knee infections treated with oral antibiotics. The PROMS findings of this trial support the clinical findings (i.e. infection eradication rates) and suggest that there is no advantage of using prolonged intravenous therapy as compared to oral therapy in the early treatment of infections around the hip and knee joint

INTRODUCTION. Short femoral stem use in total hip arthroplasty (THA) has increased due to positive short-term clinical and biomechanical success. A neck preserving femoral stem not only preserves proximal bone volume, but preserves the high quality bone of the medial neck. The short stem design allows for less invasive surgical exposure and less invasive violation of the femoral canal (Figure 1). Additionally, it facilitates future revision THA, if needed, with a conventional primary stem. The objective of this study was to evaluate the early clinical outcomes of the Alteon® Neck Preserving Femoral Stem (Exactech, Inc.). METHODS. Forty-nine subjects (25 males, 24 females; mean age: 58.3±7.6 years; mean BMI: 29.8±5.6) from 2 sites underwent primary THA with the Alteon Neck Preserving Femoral Stem. All participants signed the informed consent, and both sites received IRB approval prior to conducting the study. Clinical data outcomes for this study included the Harris Hip Score (HHS), the Oxford Hip Score (OHS), revisions, and subsidence at 3-month, 1-year, and 2-year post-operative time points. Subsidence was measured by an independent third party. Student t-tests were used to identify significant mean differences between genders (p<0.05). RESULTS. The means and standard deviations for the HHS and OHS are shown in Figures 2 and 3 respectively. For patients reaching the 2-year post-operative time point (n=28), the HHS improved by 51.3 points to 96.1 from 44.8 and the OHS improved by 23.0 points to 43.8 from 20.8. There was no significant difference between genders with regard to BMI or post-operative HHS or OHS scores. However, the females were significantly older (61.4 vs. 55.3) and had a significantly lower pre-operative HHS (44.3 vs. 53.5). There were 2 revisions reported, and there was one report of subsidence at 1 year (n=33); zero reports of subsidence at 2 years (n=24). DISCUSSION. The neck preserving femoral stem exhibited positive early clinical results as demonstrated by the marked improvement in functional outcome scores from the pre-operative visit to 2-years post-operative. These 2-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Functional outcomes scores kept improving at the 3-month, 1-year, and 2-year post-operative visits. Additional 2-year outcomes data will be incorporated into this dataset as they become available. For the two revisions, one was due to a calcar fracture and one was due to a patient fall. The patient who fell reported weight-bearing pain after the fall at the 1-year post-operative visit and was subsequently revised. Stem movement was documented as a result of the fall; this was the only report of subsidence. SIGNIFICANCE. The neck preserving femoral stem evaluated in this study demonstrated positive early clinical performance with no reports of subsidence (except for one case that was revised due to a fall). This neck preserving stem design is a promising alternative to conventional femoral stems. For any figures or tables, please contact authors directly

Objectives. Total hip arthroplasty (THA) is one of the most successful surgical procedures; several bearing technologies have been used, however none of these is optimal. Metal on polycarbonate-urethane (PCU) is a new bearing technology with several potential advantages: PCU is a hydrophilic soft pliable implant quite similar in elasticity to human cartilage, offers biostability, high resistance to hydrolysis, oxidation, and calcification, no biodegradation, low wear rate and high corrosion resistance and can be coupled with large metal heads (Tribofit Hip System, THS). The aim of this prospective study was to report the survivorship and the clinical and radiographic outcomes and the metal ions dosage of a group of patients operated with metal on PCU arthroplasty featuring large metal diameter heads, at 5 years from surgery. Study Design & Methods. 68 consecutive patients treated with the THS were included. The patients have been contacted by phone call and invited to return to our centre for clinical (Oxford Hip Score, OHS, and Harris Hip Score, HHS), radiographic exam and metal ion levels evaluation. All the patients were operated with uncemented stems. Results. The survival rate is 100% and no major complications were seen. The average preoperative OHS was 17 (6–34), at follow-up it was 44 (40–48). The average preoperative HHS was 48 (12–76), at follow-up it was 93 (84–100). On the x rays taken at follow-up, no signs of periprosthetic bone rarefaction and/or osteolysis were seen. No signs of PCU liner wear were visible. At follow up mean Co serum level was 0.52 ng/mL (<0.1–2.5, sd 0.5), mean Cr level was 0.27 ng/mL (0.1–2.2, sd 0.2). In this prospective study at a mean follow up of 5 years, all implants were well functioning, with no radiological signs of loosening and normal serum levels of cobalt and chrome. Although large diameter metal heads and metal sleeve were used no trunnionosis occurred. Conclusions. We believe that these positive outcomes are due the positive biomechanical characteristics of PCU. These results need to be confirmed at a longer follow up and in a more active younger patient population

Aim. Advocates of Debridement-Antibiotics-and-Implant-Retention (DAIR) in hip peri-prosthetic joint infection (PJI) argue that a procedure not disturbing a sound prosthesis-bone interface is likely to lead to better survival and functional outcome compared to revision. However, no evidence supports this. This case-control study's aims were to compare outcome of DAIRs for infected 1° total hip arthroplasty (THA) with outcomes following 1° THA and 2-stage revisions of infected 1° THAs. Method. We retrospectively reviewed all DAIRs, performed for confirmed infected 1° THR (DAIR-Group, n=80), in our unit between 1997–2013. Data recorded included patient demographics, medical history, type of surgery and organism identified. Outcome measures included complications, mortality, implant survivorship and functional outcome using the Oxford Hip Score (OHS). Outcome was compared with 2 control groups matched for gender and age; a cohort of 1° THA (1°-THA-Group, n=120) and a cohort of 2-stage revisions for infection (2-Stage-Revision-Group, n=66). Results. The mean age at DAIR was 69 years and mean follow-up was 8 years (SD:5). 60% of DAIRs were for early PJI (< six weeks). Greater infection eradication with DAIR was detected with early-PJI, interval less than a week between onset of symptoms and exchange of modular components with the DAIR procedure. Infection eradication, complications and re-operation rates were similar in the DAIR- and 2-stage-revision Groups (p>0.05). For hips with successful infection eradication with DAIR, the 5-yr survival (98%) was similar to the 1°THA-Group (98%) (p=0.3). The DAIR-Group had inferior OHS (38) compared to the 1°THA-Group (42) (p=0.02) but significantly better OHS compared to the 2-stage-revision-Group (31) (p=0.008). Patients that required only one DAIR for infection eradication had similar OHS (41) to the 1° THA-Group (p=0.2). Conclusions. DAIRs are associated with similar complication and infection eradication to 2-stage revisions. Exchange of modular components is advised for improved chances of infection eradication. Functional outcome following DAIRs was better than a 2-stage revision and as good as that of a 1° THA if a single DAIR was necessary for infection eradication