Aims. There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. Methods. Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m. 2. who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m. 2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. Results. No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). Conclusion. Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4–11

Aims. Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m. 2. ) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m. 2. ) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach. Methods. This retrospective cohort study observes peri- and postoperative outcomes of MO and HW patients who underwent a primary, unilateral THA with the ABMS approach. Data from surgeries performed by three surgeons at a single institution was collected from January 2013 to August 2020 and analyzed using Microsoft Excel and Stata 17.0. Results. This study compares 341 MO to 1,140 HW patients. Anaesthesia, surgery duration, and length of hospital stay was significantly lower in HW patients compared to MO. There was no difference in incidence of pulmonary embolism, periprosthetic fracture, or dislocation between the two groups. The rate of infection in MO patients (1.47%) was significantly higher than HW patients (0.14%). Preoperative patient-reported outcome measures (PROMs) show a significantly higher pain level in MO patients and a significantly lower score in functional abilities. Overall, six-week and one-year postoperative data show higher levels of pain, lower levels of functional improvement, and lower satisfaction scores in the MO group. Conclusion. The comorbidities of obesity are well studied; however, the implications of THA using the ABMS approach have not been studied. Our peri- and postoperative results demonstrate significant improvements in PROMs in MO patients undergoing THA. However, the incidence of deep infection was significantly higher in this group compared with HW patients. Cite this article: Bone Jt Open 2023;4(5):299–305

Aims. The purpose of our study is to summarise the current scientific findings regarding the impact of obesity on total hip arthroplasty (THA); specifically the influence of obesity on the timing of THA, incidence of complications, and effect on clinical and functional outcomes. Materials and Methods. We performed a systematic review that was compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prospective studies from the PubMed/Medline, Embase, and Cochrane Library databases that evaluated primary THA in obese (body mass index (BMI) ≥ 30 kg/m. 2. ) patients. Results. There were 17 articles included in the review, which encompassed 13 722 THA patients. Analysis of the included studies showed that, when compared with non-obese patients, obesity was associated with younger age at time of primary THA, and an increased incidence of complications (up to four-fold). Results were mixed on the influence of obesity on the outcomes of primary THA, with three studies showing a detrimental effect on outcomes of a BMI ≥ 30 kg/m. 2. , while eight studies showed no effect. Conclusion. Obesity is associated with significantly younger age at time of primary THA and obese patients are likely to experience a higher rate of peri-operative complications. More investigation is needed into the effect of obesity on clinical outcomes, as the current literature is mixed. Cite this article: Bone Joint J 2017;99-B(1 Supple A):31–6

Obesity is a risk factor for complications following many orthopaedic procedures. The purpose of this study was to investigate whether obesity was an independent risk factor increasing the rate of complications following periacetabular osteotomy (PAO) and to determine whether radiographic correction after PAO was affected by obesity. . We retrospectively collected demographic, clinical and radiographic data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were followed for a mean of 48 months (12 to 60) after PAO. A total of 65 patients (23.2%) were obese (body mass index (BMI) > 30 kg/m. 2. ). Univariate and multivariate analysis demonstrated that BMI was an independent risk factor associated with the severity of the complications. The average probability of a patient developing a major complication was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient The odds of a patient developing a major complication were 11 times higher (95% CI 4.71 to 17.60, p <  0.0001) for an obese compared with a non-obese patient. . Following PAO surgery, there was no difference in radiographic correction between obese and non-obese patients. PAO procedures in obese patients correct the deformity effectively but are associated with an increased rate of complications. Cite this article: Bone Joint J 2015;97-B:29–34

Introduction. The purpose of this study is to estimate the cost-effectiveness of performing total hip arthroplasty (THA) versus nonoperative management (NM) in non-obese (BMI 18.5–24.9), overweight (25–29.9), obese (30–34.9), severely-obese (35–39.9), morbidly-obese (40–49.9), and super-obese (50+) patients. Methods. We constructed a state-transition Markov model to compare the cost-utility of THA and NM in the six above-mentioned BMI groups over a 15-year time period. Model parameters for transition probability (i.e. risk of revision, re-revision, death), utility, and costs (inflation adjusted to 2017 US dollars) were estimated from the literature. Direct medical costs of managing hip arthritis were accounted in the model. Indirect societal costs were not included. A 3% annual discount rate was used for costs and utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) of THA versus NM. One-way and Monte Carlo probabilistic sensitivity analysis of the model parameters were performed to determine the robustness of the model. Results. Over the 15-year time period, the ICERs for THA versus NM were: normal-weight ($6,043/QALY), overweight ($5,770/QALY), obese ($5,425/QALY), severely-obese ($7,382/QALY), morbidly-obese ($8,338/QALY), and super-obese ($16,651/QALY). The two highest BMI groups had higher incremental QALYs and incremental costs. The probabilistic sensitivity analysis suggests that THA would be cost-effective in 100% of the normal, overweight, obese, severely-obese, and morbidly-obese simulations, and 99.95% of super-obese simulations at an ICER threshold of $50,000/QALY. Conclusion. Even at a willingness-to-pay threshold of $50,000/QALY, which is considered low for the United States, our model showed that THA would be cost effective for all obesity levels. Therefore, invoking BMI cut-offs for THA may lead to unjustifiable loss of healthcare access for obese patients with end-stage hip osteoarthritis

Osteoarthritis (OA) of the hip is the most common indication for total hip replacement (THR). Obesity is a risk factor for the development of OA and has recently resulted in patients requiring THRs at much younger ages to relieve pain at the joint capsule and restore mobility. However, the impact of obesity on THR mortality is not well understood. An updated systematic review was performed to identify whether an obese BMI should influence patient selection for surgery. Specifically, the impact of obesity on short-term mortality, long-term mortality, and peri- and post-operative complications was assessed with a particular focus on BMI classes. A comprehensive literature search of Ovid Medline and EMBASE in November 2022 identified relevant papers in accordance with PRISMA methodology. After removing duplicates, 2988 articles underwent strict inclusion and exclusion criteria, resulting in 12 papers for analysis. There was no statistically significant difference in mortality risk between obese and non-obese populations. Obesity was associated with a lower risk of short-term mortality than in the normal weight control group, however there was an increased mortality risk in obese patients long-term likely due to comorbidities. Obese patients were significantly younger than normal BMI and underweight patients. However, the paper found increased mortality risk in underweight and morbidly obese patients. Obese patients did not have an increased risk of mortality when compared to non-obese patients following THR. Obesity may have a protective effect on mortality up to a BMI of 40kg/m2, although this may be influenced by the obesity paradox which states only the healthiest obese individuals are selected for surgery, which could attribute to a lower mortality risk. The greatest risk of mortality and complication was associated with underweight patients. As a result, a BMI greater than 30kg/m2 may not necessitate a hip replacement contraindication. It is important surgeons apply careful consideration and comprehensive risk assessment on patients who require a THR, especially at the BMI extremes

A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes. The patients were categorised into three groups: non-obese (body mass index (BMI) < 30 kg/m. 2. ), obese (BMI 30 to 40 kg/m. 2. ) and morbidly obese (BMI > 40 kg/m. 2. ). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%). There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients

Purpose. Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. Materials & Methods. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. Results. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. Conclusions. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

We evaluated the outcome of primary total hip replacement (THR) in 3290 patients with the primary diagnosis of osteoarthritis at a minimum follow-up of two years. They were stratified into categories of body mass index (BMI) based on the World Health Organisation classification of obesity. Statistical analysis was carried out to determine if there was a difference in the post-operative Western Ontario and McMaster Universities osteoarthritis index, the Harris hip score and the Short-Form-12 outcome based on the BMI. While the pre- and post-operative scores were lower for the group classified as morbidly obese, the overall change in outcome scores suggested an equal if not greater improvement compared with the non-morbidly obese patients. The overall survivorship and rate of complications were similar in the BMI groups although there was a slightly higher rate of revision for sepsis in the morbidly obese group. Morbid obesity does not affect the post-operative outcome after THR, with the possible exception of a marginally increased rate of infection. Therefore withholding surgery based on the BMI is not justified

The outcome of total hip replacement (THR) is potentially affected by the body mass index (BMI) of the patient. We studied the outcome of 2026 consecutive primary cementless THRs performed for osteoarthritis. The mean follow-up was 6.3 years (0 to 11.71) and no patient was lost to follow-up for survival analysis. The patients were divided into two groups according to their BMI as follows: non-obese (BMI < 30 kg/m. 2. ) and obese (BMI ≥ 30 kg/m. 2. ). The obese patient undergoing surgery was found to be significantly younger (p < 0.001). The log-rank test for equality of survival showed no difference in the mid-term survival (p = 0.552) with an estimated survival at 11 years of 95.2% (95% CI 92.5 to 98.0) in the non-obese and 96.7% (95% CI 94.9 to 98.5) in the obese groups. The clinical and radiological outcome was determined in a case-matched study performed on 134 obese individuals closely matched with 134 non-obese controls. The non-obese group was found to have a significantly higher post-operative Harris hip score (p < 0.001) and an increased range of movement, but overall satisfaction with surgery was comparable with that of the obese patients. Radiological analysis of the acetabular and femoral components showed no significant differences with regard to radiolucent lines, osteolysis, ingrowth of the femoral component, the acetabular inclination angle or alignment of the femoral component. Our results suggest that the survival of cementless THR is not adversely affected by obesity. Obese patients can therefore be counselled that despite a lower clinical score, they should expect to be satisfied with the result of their THR with a mid-term survival rate equivalent to that of non-obese patients

We compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings. Survival at five years using revision surgery as an endpoint, was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the non-obese group (p < 0.001). The morbidly obese patients had a higher rate of complications (22% vs 5%, p = 0.012), which included dislocation and both superficial and deep infection. In light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life

We studied a consecutive series of 285 uncemented total hip replacements in 260 patients using the Taperloc femoral component and the T-Tap acetabular component. The outcome of every hip was determined in both living and deceased patients. A complete clinical and radiological follow-up was obtained for 209 hips in 188 living patients, followed for a mean of 14.5 years (10 to 18.9). They were divided into two groups, obese and non-obese, as determined by their body mass index. There were 100 total hip replacements in 89 patients in the obese cohort (body mass index ≥ 30 kg/m. 2. ), and 109 in 99 non-obese (body mass index < 30 kg/m. 2. ) patients. A subgroup analysis of 31 patients of normal weight (body mass index 20 kg/m. 2. to 25 kg/m. 2. ) (33 hips) and 26 morbidly obese patients (body mass index ≥ 35 kg/m. 2. ) (30 hips) was also carried out. In the obese group five femoral components (5%) were revised and one (1%) was loose by radiological criteria. Femoral cortical osteolysis was seen in eight hips (8%). The acetabular component was revised in 57 hips (57%) and a further 17 (17%) were loose. The mean Harris hip score improved from 52 (30 to 66) pre-operatively to 89 (49 to 100) at final follow-up. Peri-operative complications occurred in seven patients (7%). In the non-obese group six (6%) femoral components were revised and one (1%) was loose. Femoral cortical osteolysis occurred in six hips (6%). The acetabular component was revised in 72 hips (66%) and a further 18 (17%) were loose. The mean Harris hip score increased from 53 (25 to 73) prior to surgery to 89 (53 to 100) at the time of each patient’s final follow-up radiograph. No statistically significant difference was identified between the obese and non-obese patients with regards to clinical and radiological outcome or complications. The subgroup analysis of patients of normal weight and those who were morbidly obese showed no statistically significant difference in the rate of revision of either component. Our findings suggest there is no evidence to support withholding total hip replacement from obese patients with arthritic hips on the grounds that their outcome will be less satisfactory than those who are not obese

The burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015), chronic obstructive pulmonary disease (p=0.016), renal disease (p=0.009), and mental illness (p=0.03). Increased body mass index (BMI) was not associated with a significant increase in LOS (r=0.01, p=0.83). Increased readmission rates were associated with comorbidities including hypertension (p=<0.0001), coronary artery disease (p=<0.0001), congestive heart failure (p=0.0007), peripheral vascular disease (p=<0.0001), chronic obstructive pulmonary disease (p=0.003), asthma (p=0.0128), renal disease (p=0.0001), and mental illness (p=0.0147). Obesity was not associated with increased readmission rates until the patients were morbidly obese (>40 BMI; p=0.03). Although the LOS decreased over the time of the study, this did not result in an adverse increase in readmission rates. Several comorbidities including hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and mental illness were all associated with both a longer LOS and an increase in readmission rates. Asthma was associated with increased readmission rates only and diabetes was associated with an increased LOS only. BMI was not associated with readmission rates unless the BMI exceeded 40 and had no significant effect on LOS at any BMI level

The presence of obesity has negative influence on the progress of osteoarthritis and increases the risk of undergoing a primary THA at an earlier age. However, the correlation of BMI and the risk for postoperative complications, revision surgery and infection rate is still controversial. In the largest cohort to this date, we used the German insurance claims database to evaluate the correlation of BMI and the risk of postoperative complications, mortality and revision rates following primary THA. Using nationwide billing data of the German health-care insurance for inpatient hospital treatment, we identified patients over the age of 20 years who had undergone either THA or short-stem THA between January 2012 and December 2014. BMI was classified into four groups (< 30 kg/m², 30 to 34.9 kg/m², 35 to 39.9 kg/m², > 40 kg/m²). In all patients, the 90-day complication, mortality and revision rates were calculated. Furthermore, all complications and revisions were determined at a latest follow-up of 1 year. We used multivariable logistic regression to model the odds of complications as a function of BMI groups. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 131,576 total hip arthroplasties in 124,368 patients were included for final analysis. BMI had a significant effect on risk adjusted 1-year overall complications, 1-year revision surgery and 90-day surgical complications. The adjusted odd ratios increased significantly with BMI category. Especially morbidly obese patients with a BMI >40 kg/m. 2. had a threefold higher risk for deep infection and a two-fold higher risk for the overall complication and revision rates as compared to patients with a BMI <30 kg/m. 2. . Obesity plays an important role in patients undergoing primary THA, especially patients with a BMI beyond 40 kg/m. 2. have a markedly higher risk for revision surgery and overall complication rates. This study aims to increase awareness among physicians in order to improve risk stratifications and to better educate patients with regard to obesity and postoperative expectations prior to undergoing elective total hip arthroplasty

Aims. Previous research has demonstrated increased early complication rates following total hip arthroplasty (THA) in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth (FD) has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery, as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peritrochanteric FD was associated with an increased risk of complications in the first year following THA. Methods. We analyzed prospectively collected data on a consecutive series of 1,220 primary THAs from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured intraoperatively using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient’s preoperative assessment. All surgical complications occuring within the initial 12 months of follow-up were identified. Results. Females had a significantly greater FD at the greater trochanter in comparison to males (median 3.0 cm (interquartile range (IQR) 2.3 to 4.0) vs 2.0 cm (IQR 1.7 to 3.0); p < 0.001) despite equivalent BMI between sexes (male median BMI 30.0 kg/m. 2. (IQR 27.0 to 33.0); female median 29.0 kg/m. 2. (IQR 25.0 to 33.0)). FD showed a weak correlation with BMI (R² 0.41 males and R² 0.43 females). Patients with the greatest FD (upper quartile) were at no greater risk of complications compared with patients with the lowest FD (lower quartile); 7/311 (2.3%) vs 9/439 (2.1%); p = 0.820 . Conversely, patients with the highest BMI (≥ 40 kg/m. 2. ) had a significantly increased risk of complications compared with patients with lower BMI (< 40 kg/m. 2. ); 5/60 (8.3% vs 18/1,160 (1.6%), odds ratio (OR) 5.77 (95% confidence interval (CI) 2.1 to 16.1; p = 0.001)). Conclusion. We found no relationship between peritrochanteric FD and the risk of surgical complications following primary THA. Cite this article: Bone Joint J 2020;102-B(9):1146–1150

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

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

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. Methods. In this longitudinal register-based observational study, we identified 72,069 patients with hip and knee OA in the Better Management of Patients with Osteoarthritis Register (BOA), who were referred for first-line OA intervention, between May 2008 and December 2016. Patients were followed until the first primary arthroplasty surgery before 31 December 2016, stratified into a hip and a knee OA cohort. Data were analyzed with Kaplan-Meier and multivariable-adjusted Cox regression. Results. At five years, Kaplan-Meier estimates showed that 46% (95% confidence interval (CI) 44.6 to 46.9) of those with hip OA, and 20% (95% CI 19.7 to 21.0) of those with knee OA, had progressed to arthroplasty. The strongest prognostic factors were desire for surgery (hazard ratio (HR) hip 3.12 (95% CI 2.95 to 3.31), HR knee 2.72 (95% CI 2.55 to 2.90)), walking difficulties (HR hip 2.20 (95% CI 1.97 to 2.46), HR knee 1.95 (95% CI 1.73 to 2.20)), and frequent pain (HR hip 1.56 (95% CI 1.40 to 1.73), HR knee 1.77 (95% CI 1.58 to 2.00)). In hip OA, the probability of progression to surgery was lower among those with comorbidities (e.g. ≥ four conditions; HR 0.64 (95% CI 0.59 to 0.69)), with no detectable effects in the knee OA cohort. Instead, being overweight or obese increased the probability of OA progress in the knee cohort (HR 1.25 (95% CI 1.15 to 1.37)), but not among those with hip OA. Conclusion. Patients with hip OA progressed faster and to a greater extent to arthroplasty than patients with knee OA. Progression was strongly influenced by patients’ desire for surgery and by factors related to severity of OA symptoms, but factors not directly related to OA symptoms are also of importance. However, a large proportion of patients with OA do not seem to require surgery within five years, especially among those with knee OA. Cite this article: Bone Joint J 2022;104-B(7):792–800

Introduction. The obesity epidemic is a growing problem and must be considered with the projected increased demand for total hip arthroplasty (THA). Previous studies have reported increased complication rates after THA in the obese population, which has led to hesitation in offering surgery to this population. Moreover, some insurers are denying coverage for morbidly obese patients. While many consider obesity a “modifiable” risk factor, very few patients with advanced osteoarthritis have successfully lost substantial weight. The experience of centers that utilize systematic preoperative risk stratification tools and standardized postoperative total joint pathways may be underrepresented in prior studies. The aim of this study is to describe one surgeon's experience performing THA in morbidly and super-obese patient populations using an institutional preoperative Risk Stratification Tool (RST) and total joints pathway. Methods. We conducted a retrospective review of patients undergoing primary THA between May 2014 and December 2017 performed by a single surgeon at a tertiary care referral center. All patients were assessed preoperatively using an institutional RST and had a minimum of 90-day postoperative follow up. Patients were stratified by body mass index (BMI, kg/m. 2. ): non-obese (BMI < 30), obese (30–34), severely obese (35–39), morbidly obese (40–44), and super-obese (≥ 45). Primary outcomes were inpatient and 90-day complications. Continuous and binary parameters were analyzed by Kruskal-Wallis and Fisher exact tests. Logistic regression was additionally utilized to evaluate outcomes by BMI cohort. Results. A consecutive series of 368 patients met inclusion criteria across all BMI cohorts. There was significant variation with respect to age (P=0.001), BMI (P<0.001), diabetes (P=0.008), ASA class (P<0.001), and anesthesia type (P=0.003) (Table 1). Variation among BMI cohorts was also identified for several operative and postoperative parameters, including longer operative and in-room time and greater length of stay (P<0.001) (Table 2). Compared to non-obese patients, super-obese patients had 20.1 greater odds of return to OR within 90 days for superficial surgical site infection (SSI) or prolonged round drainage (P=0.008) (Table 3). Notably, morbidly and super-obese patients were not at significantly increased risk for inpatient intensive care unit (ICU) transfer, blood transfusion, 90-day emergency room visit, or 90-day readmission compared to their non-obese counterparts. For patients in whom 1-year follow-up was available, these differences between BMI cohorts remained insignificant. Conclusions. Patients with BMI>40 are more likely than non-obese patients to have increased postoperative rehabilitation needs but are not at increased risk for in-hospital complications. Super-obese patients have greater risk of superficial SSI or prolonged wound drainage than non-obese patients but are not at increased risk for revision or deep infection in any cohort. Use of a preoperative RST may help to mitigate postoperative complications and readmissions previously associated with morbid and super-obesity. We conclude that THA can be safely performed in super-obese patients and therefore care should not be denied to this population. Summary sentence. Total hip arthroplasty (THA) can be safely performed in morbidly and super-obese patients with the use of a preoperative risk stratification tool (RST) and total joints pathway. For any tables or figures, please contact the authors directly