Young Adult Hip [YAH] pathology is now better recognised and treated than decades ago. However, our patients have suggested to us that they encountered delays in recognition and referral.

For the past four years incoming referrals of YAH have been questioned away from the ROH clinic environment in groups of 100 incoming referrals by TS Gambling, Senior Lecturer in Psychology.

Time from onset of symptoms to clinic attendance; number of GP visits; Consultants seen before accurate diagnosis; validity of earlier investigations; severity and effects of symptoms on their daily lives and careers; social effects; body image; self-confidence; oxford hip scores.

The median age was 28 years; the mean delay in being seen at a YAH clinic was 8.3–8.6 years.

The mean number of consultants seen before the YAH clinic was 2.3 – 2.6.

Fewer than 5% were properly investigated by these consultants.

The mean oxford hip score was 30; in only 8% was it less than 20, the common level for hospital referral.

22% were unable to work. In 8% their career was unaffected.

Although 70% were working or pursuing a career, almost all required adaptations /redeployment to sedentary work/Long-term sickness testing employers' tolerance/Intermittent sickness/putting off promotion/ further education/part time working/change of career.

Only 8% were unaffected at work.

In addition, there were profound social effects upon self-esteem, body image, relationships, as well as comfort during sex.

These results do not make comforting news.

In addition to the above difficulties, all our patients expressed; Powerlessness; Frustration; Anger; Not being listened to; being unsupported; Undermined; Humiliation.

The family doctor/ GP services are poor at appreciating the disability in YAH patients.

YAH onset is characteristically at 19.5 years, just when youngsters are becoming independent and self-reliant.

The OHS is an invalid/misleading discriminator in these patients when considering referral.

The hospital orthopaedic service is poor at recognising and investigating YAH disease.

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA

Aims. Social media is a popular resource for patients seeking medical information and sharing experiences. periacetabular osteotomy (PAO) is the gold-standard treatment for symptomatic acetabular dysplasia with good long-term outcomes. However, little is known regarding the perceived outcomes of PAO on social media. The aims of this study were to describe the perceived outcomes following PAO using three social media platforms: Facebook, Instagram, and X (formerly known as Twitter). Methods. Facebook, Instagram, and X posts were retrospectively collected from 1 February 2023. Facebook posts were collected from the two most populated interest groups: “periacetabular osteotomy” and “PAO Australia.” Instagram and X posts were queried using the most popular hashtags: #PAOwarrior, #periacetabularosteotomy, #periacetabularosteotomyrecovery, #PAOsurgery, and #PAOrecovery. Posts were assessed for demographic data (sex, race, location), perspective (patient, physician, professional organization, industry), timing (preoperative vs postoperative), and perceived outcome (positive, negative, neutral). Results. A total of 1,054 Facebook posts, 1,003 Instagram posts, and 502 X posts were consecutively assessed from 887 unique authors. The majority (63.3%) of these posts were from patients in the postoperative period, with a median of 84 days postoperatively (interquartile range 20 to 275). The longest follow-up timeframe postoperatively was 20 years. Regarding perceived outcomes, 52.8% expressed satisfaction, 39.7% held neutral opinions, and 7.5% were dissatisfied. Most dissatisfied patients (50.9%) reported pain (chronic or uncontrolled acute) as an attributing factor. Conclusion. Most PAO-perceived surgical outcomes on social media had a positive tone. Findings also indicate that a small percentage of patients reported negative perceived outcomes. However, dissatisfaction with PAO primarily stemmed from postoperative pain. Social media posts from other sources (physicians, hospitals, professional organizations, etc.) trend towards neutrality. Healthcare providers must consider the social media narratives of patients following PAO, as they may reveal additional outcome expectations and help improve patient-centred care, create informed decision-making, and optimize treatment outcomes. Cite this article: Bone Jt Open 2024;5(1):53–59

Aims. The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England. Methods. This retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation. Results. Among 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001). Conclusion. The cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL. Cite this article: Bone Joint J 2022;104-B(7):811–819

Severe heterotopic ossification (grade III and IV) after contemporary total hip arthroplasty (THA) requiring excision is very uncommon. We performed a systematic review of the literature, and report a new case series with operative treatment after primary uncemented THA. A systematic review identified papers describing patients who had excision of heterotopic ossification (HO) after contemporary THA, defined as performed after 1988. Concepts of hip arthroplasty, heterotopic ossification, and surgical excision were searched in MEDLINE, Embase, and Scopus, from database inception to November 2022. Inclusion criteria were: articles that included specific patient data on grade of heterotopic ossification, operative procedure, and prophylaxis. Studies were screened for inclusion by two independent reviewers. Extracted data included demographic data, interval from index surgery to excision, clinical results, and complications. One surgeon performed reoperation for ankylosis of primary THA in three patients with severe pain and deformity. Seven case series or case report studies were included. There were 41 patients, with grade III or IV HO, that had excision, and in five patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation, one gastrointestinal complication, and two recurrences. Treatment of the three patients, with wide excision of peri-articular bone, selective exchange of components, and peri-operative irradiation prophylaxis, was successful in improving motion and deformity. There is insufficient data on the treatment of severe symptomatic HO after contemporary THA. Prophylaxis with low-dose irradiation was successful to prevent recurrence. Multicenter studies will be needed to determine the optimum timing and prognosis for treatment

Developmental dysplasia of the hip can cause pain and premature osteoarthritis. However, the risk factors and timing for disease progression in young adults are not fully defined. This study identified the incidence and risk factors for contralateral hip pain and surgery after periacetabular osteotomy (PAO) on an index dysplastic hip. Patients followed for 2+ years after unilateral PAO were grouped by eventual contralateral pain or no-pain, based on modified Harris Hip Score, and surgery or no-surgery. Univariate analysis tested group differences in demographics, radiographic measures, and range-of-motion. Kaplan-Meier survival analysis assessed pain development and contralateral hip surgery over time. Multivariate regression identified pain and surgery risk factors. Pain and surgery predictors were further analyzed in Dysplastic, Borderline, and Non-dysplastic subcategories, and in five-degree increments of lateral center edge angle (LCEA) and acetabular inclination (AI). 184 patients were followed for 4.6±1.6 years, during which 51% (93/184) reported hip pain and 33% (60/184) underwent contralateral surgery. Kaplan-Meier analysis predicted 5-year survivorship of 49% for pain development and 66% for contralateral surgery. Painful hips exhibited more severe dysplasia than no-pain hips (LCEA 16.5º vs 20.3º, p<0.001; AI 13.2º vs 10.0º p<0.001). AI was the sole predictor of pain, with every 1° AI increase raising the risk by 11%. Surgical hips also had more severe dysplasia (LCEA 14.9º vs 20.0º, p<0.001; AI 14.7º vs 10.2º p<0.001) and were younger (21.6 vs 24.1 years, p=0.022). AI and a maximum alpha angle ≥55° predicted contralateral surgery. 5 years after index hip PAO, 51% of contralateral hips experience pain and 34% percent are expected to need surgery. More severe dysplasia, based on LCEA and AI, increases the risk of contralateral hip pain and surgery, with AI being a predictor of both outcomes. Knowing these risks can inform patient counseling and treatment planning

Hip arthroscopy (HA) is an effective treatment for various hip conditions but has a steep learning curve and its effect on long-term joint preservation is unclear. This study uses population-level data to assess (1) the 90-day complication rate, and (2) the frequency and timing of revision HA, total hip replacement (THR), and pelvic osteotomy (PO) following primary HA. We performed a retrospective analysis of the National Hospital Episode Statistics database, examining all patients who underwent primary HA in NHS hospitals in England from 2010 to 2023 using relevant OPCS-4 codes. We evaluated patient demographics, 90-day complications, and reoperation rates for revision HA, THR, and PO. Descriptive statistical analyses were performed to calculate frequencies and average time to reoperations. We included 22,401 HA procedures in the study. The mean LOS was 0.82±2.04 days. The 90-day readmission rate was 0.17% at a mean of 54.4±8.1 days. The most common reasons for readmission were reoperation (0.071%), followed by infection (0.031%), pulmonary embolism (0.027%), pain (0.022%), bleeding (0.018%), and deep vein thrombosis (0.004%). One patient died within 90 days. Overall, 4942 patients (22.1%) required further surgery at a mean of 2.71±2.27 years. The rates of revision HA, conversion to THR, and PO were 6.94%, 14.6%, and 0.50% at a mean of 2.39±1.79, 2.87±2.46, and 2.26±1.80 years respectively. Female patients had higher rates of reoperation than males for conversion to THR (9.99% vs 4.63%), revision HA (4.92% vs 2.02%), and subsequent PO (0.43% vs. 0.06%) (p<0.001). This study demonstrates a low short-term complication rate after primary HA, supporting existing literature. However, a large proportion of patients required further surgery, especially females. These findings highlight the need for careful patient selection and counselling before HA to optimise outcomes, as well as further research on factors influencing longer-term outcomes and cost-effectiveness

Hip dysplasia is a common cause of hip pain in young adults. Pelvic osteotomy (PO) techniques are the gold standard for treating symptomatic patients, albeit technically demanding. This study aimed to (1) evaluate the 90-day complication rate, and (2) investigate the reasons, frequency and timing of reoperations following primary PO procedures. We retrospectively analysed the National Hospital Episode Statistics database, examining all patients aged over 14 who underwent PO in NHS England hospitals from 2010 to 2023. We identified index procedures and reoperations using relevant OPCS-4 codes. We analysed patient demographics, 90-day complications, and readmission rates for ipsilateral metalwork removal, revision PO, hip arthroscopy (HA), and THR conversion, and calculated the mean time to reoperations. This study included 1,348 PO cases (mean age: 28.7±9.1 years, 89.5% female). The mean hospital stay was 5.4±3.9 days, with a 90-day readmission rate of 0.52% at a mean of 51.0±17.2 days. The most common causes were infection (0.22%) and reoperation (0.15%). The 90-day rate of pulmonary embolism and deep vein thrombosis was 0.074%. One patient died within 90 days. Overall, 810 patients (60.1%) were readmitted for a subsequent hip procedure at a mean of 2.12±1.90 years following their primary PO. Metalwork removal was required in 616 patients (45.7%) at a mean of 1.70±1.19 years. Readmission rates for revision PO, HA, and THR, were 4.23% (mean time: 2.89±0.82 years), 4.15% (mean time: 2.91±2.28 years) and 6.01% (mean time: 5.24±3.08 years) respectively. This study highlights a low 90-day complication rate following primary PO, but a high reoperation rate, mainly for metalwork removal. We provide the most up-to-date report of revision PO, HA and THR conversion rates in England. These findings provide valuable insight that can facilitate informed decision-making, expectation-setting, and post-operative planning, also establishing a benchmark for future quality improvement

Total Hip Arthroplasty (THA) surgery is a physical and cognitive challenge for surgeons. Data on stress levels, cognitive and physical load of orthopaedic surgeons, as well as ergonomic impact, are limited. With and without the use of an automated impaction device, operational efficiency and the surgeon's ergonomic, mental, and physical load was investigated. In a total of thirty THA procedures, a standard manual technique was compared with an automated impaction device. Three computerized cognitive tasks (Simon, pattern comparison, and pursuit rotor) and five physical tests (isometric wall-sit, plank-to-fatigue, handgrip, supra-postural task, and shoulder endurance) were used to assess psychophysiological load of the surgeon. Surgeon's cortisol concentration was evaluated from saliva samples. Postural risk was assessed by Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Efficiency was assessed by timing surgical steps and instrumentation flow. Cognitive performances after automated impaction showed faster response times and lower error rates with a greater time-on-target (+1.5 s) and a lower mouse deviation from target (−1.7 pixels). Manual impaction showed higher physical exhaustion in the isometric wall-sit test (10.6% vs. 22.9%), plank-to-fatigue (2.2% vs. 43.8%), the number of taps in the supra-postural task (−0.7% vs. −7.7%), handgrip force production in the dominant (−6.7% vs. −12.7%) and contralateral hand (+4.7% vs. +7.7%), and in shoulder endurance (−15s vs. −56s). An increase of 38.2% in salivary cortisol concentration between the midday (1.31 nmol/l) and afternoon session (1.81 nmol/l) was observed with manual impaction. After using automated impaction, salivary cortisol concentration decreased (−51.2%). Manual broaching time was on average 6′20’’ versus 7’3’’ with automated impaction. RULA of manual impaction scored 6 for cup impaction and 5 for femoral broaching, versus 3 and 3 for automated impaction, respectively. REBA of manual impaction scored 9 for cup impaction and 5 for femoral broaching, versus 4 and 3 for automated impaction, respectively. Automated impaction lowers surgeons’ cognitive and physical fatigue and leads to reduced stress and improved ergonomics without loss of surgical efficiency

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Aims. We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). Methods. We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. Results. There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. Conclusion. If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79–86

Aims. The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks. Methods. Data were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data. Results. Hip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)). Conclusion. COVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk. Cite this article: Bone Joint Open 2020;1-9:530–540

Background. Cam morphology develops during adolescence and predisposes individuals to future hip pain and osteoarthritis. An improved understanding of cam development is required to determine whether the process is modifiable. Hypothesis/Purpose. The aim of this study was to characterise the risk factors, timing, and pathogenesis of cam formation. Study Design. Longitudinal prospective observational cohort study. Methods. Longitudinal observational cohort study over three years of individuals from football club academies and an age-matched control population, aged 9–18 years at baseline. Assessments include questionnaires, clinical examination, and MRI of both hips. Alpha angle and epiphyseal extension were measured on radial images. Results. Cohort comprised male academy footballers (121 at baseline and 78 at follow-up) and male and female controls (107 at baseline and 71 at follow-up). Mean change in cartilage alpha angle was 12.4° (SD 8.4) for footballers, 7.3° (SD 6.0) for male controls and 4.0° (SD 4.1) for female controls. A positive correlation was found between Physical Activity Questionnaire Score and change in cartilage alpha angle (coefficient 0.787, p=<0.001). The greatest change in cartilage alpha angle occurred in individuals aged 11–12 years at baseline, with no significant change after 14 years of age. A positive correlation between mean cartilage alpha angle and lateral epiphyseal extension was observed (r. 2. = 0.294, p=0.029). Conclusions. Males undertaking intense sporting activity during adolescence at greatest risk of developing cam morphology, but there is no significant change in hip morphology after 14 years of age. The findings are consistent with physiological adaptation and epiphyseal extension in response to hip loading during skeletal immaturity

Aims. Urinary catheter use in the peri-operative and post-operative phase following arthroplasty may be associated with increased risk of urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on routine use of antibiotics for urinary catheter insertion and removal following arthroplasty. Methods. Electronic databases were searched using the HDAS interface. Grey literature was also searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity a narrative approach was adopted. Methodological quality of each study was assessed using the CASP appraisal tool. Included studies were found to have moderate to good methodological quality. Results. A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these 1475 (31%) were undertaken on men and 3189 (68%) on women. The mean age of the study participants was 69 years. 3489 cases (74.3%) related to hip arthroplasty and 629 of cases (13.4%) to knee arthroplasty. 578 cases (12.3%) specified either hip or knee arthroplasty. In total, 45 PJIs were reported across all studies (0.96%). Two of the studies found either no PJI or no statistical difference in the rate of PJI when antibiotic prophylaxis was not used for catheter manipulation. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Rates of bacteriuria varied greatly between studies and depend on timing of sample and gender. Increased duration of urinary catheterisation is positively associated with UTI. Conclusion. It remains difficult to justify the routine use of prophylactic antibiotics for catheter manipulation in well patients undergoing arthroplasty. Their use is not recommended for this indication

Introduction. Previous reports have investigated the correlation between time to revision hip arthroplasty (rTHA) and reason for revision, but little is known regarding the impact of timing on outcomes following rTHA. The purpose of this study is to evaluate the effect of time to rTHA on both indication and outcomes of rTHA. Methods. This retrospective observational study reviewed patients who underwent unilateral, aseptic rTHA at an academic orthopedic specialty hospital between January 2016 and April 2019 with at least 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary THA (pTHA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared between the groups. Post-hoc power analysis was performed (1-β=0.991). Results. 188 cases were identified, with 61 hips undergoing early revision and 127 undergoing late revision. There were no differences in demographics and comorbidities between the groups. Type of revision differed between the groups, with early revisions having a greater proportion of femoral revisions (54.1% vs.20.5%) and late revisions having a greater proportion of both component (10.2% vs.6.6%), acetabular (30.7% vs.26.2%), or head/liner (38.6% vs. 13.1%;p< 0.001) revisions. Indication for index revision differed between the groups, with early revisions having a greater proportion for dislocation/instability (21.3% vs. 10.2%) and peri-prosthetic fracture (42.6% vs.9.4%), and late revisions having a greater proportion for loosening/osteolysis (40.9% vs.24.6%), metal-on-metal complications (11.0% vs.0.0%), and liner wear (18.9% vs.0.0%;p< 0.001). Early revisions experienced longer length of stay (LOS; 5.18±4.43 vs.3.43±2.76 days;p=0.005) and more often underwent reoperation (8.2% vs 1.6%;p=0.037). Conclusions. Early aseptic revisions had worse outcomes with longer LOS and higher rates of reoperation. These differences may be attributable to the type and indication for revision. Arthroplasty surgeons should be aware of these differences when counseling patients after THA

Introduction. A staging system has been developed to revise the 1994 ARCO classification for ONFH. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. Radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) scans may all be involved in diagnosing ONFH; however, the optimal diagnostic modality remains unclear. The purpose of this study was to identify: 1) how ONFH is diagnosed at a single academic medical center, and 2) if CT is a necessary modality for diagnosing/staging OFNH. Methods. The EMR was queried for the diagnosis of ONFH between 1/1/2008–12/31/2018 at a single academic medical center. CT and MRI scans were reviewed by the senior author and other contributors. The timing and staging quality of the diagnosis of ONFH were compared between MRI and CT to determine if CT was a necessary component of the ONFH work-up. Results. There were 803 patients with ONFH over the 10 years of study. 382 had CT only, 166 had MRI only, and 255 had both a CT and MRI. Of the 255 patients who had both CT and MRI, 228 actually had ONFH after inspection. A diagnosis of ONFH was made by MRI only in 57% (129/228) while another 21% (48/228) used MRI and CT simultaneously. 22% (51/228) of cases were diagnosed by CT scan first. 94% (48/51) of these cases involved a cancer (CA) diagnoses, the CT scans were used for CA staging and were not helpful with ARCO staging of ONFH. The other 3 cases identified asymptomatic ONFH. MRI scans performed after diagnosis with CT in symptomatic patients were then utilized for staging. Conclusion. Although CT scan was a useful adjunct for diagnosing ONFH during a staging workup for CA, it was not useful for ARCO staging of ONFH and treatment decisions. Based on this retrospective study, CT scan is not necessary when using the Revised ARCO Staging System

Hip fracture is a common injury with a high associated mortality. Many recommendations regarding timing of operative intervention exist for patients with such injuries. The Best Practice Tariff was introduced in England and Wales in 2010, offering financial incentives for surgery undertaken within 36 hours of admission. The England and Wales National Institute for Health and Clinical Excellence (NICE) Guidance states that surgery should be performed on the day or day after admission. Due to lack of clear evidence, this recommendation is based on Humanitarian grounds. NICE have called for further research into the effect of surgical timing on mortality. We utilised data from the National Hip Fracture database prospectively collected between 2007 and 2015, comprising 413,063 hip fractures. Using 11 variables, both Cox and Logistic regression analysis was used to establish the effect on mortality of each 12 hour interval from admission to surgery. For each 12 hour time frame from admission to surgery a trend for improved 30 day survival was demonstrated the earlier the surgery was performed. However, this did not reach significance until beyond 48 hours (Hazard ratio of 1.12, 95% CI: 1.04–1.20). Surgery after 48 hours suffered significantly higher chance of mortality compared to surgery done within 12 hours. This is the largest analysis undertaken to date. Lowest mortality rates are found within the 0–12 hour window. After 48 hours there is a significant increased risk of mortality compared to the 0–12 hour time frame. As such, expeditious surgery within 48 hours can be justified both on humanitarian and survivorship grounds. Hip fracture surgery performed within 48 hours is associated with reduced mortality when compared to that beyond this time. This is in agreement with Blue Book recommendations and extends the currently recommended NICE and Best Practice Tariff targets of 36 hours

Aims. Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. Patients and Methods. A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. Results. TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). Conclusion. In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis

Aims

Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

Introduction. Total Hip Arthroplasty has been shown to have excellent long term outcomes, yet early reoperation remains a risk. The current study assesses the incidence, causes, and cost associated with early revision following elective primary THA in the US Medicare population. Methods. The study used the Limited Data Set (LDS) from the Centers for Medicate and Medicaid Services (CMS) to identify all primary THA (DRG 469/470) performed in the US (excluding Maryland) during 2016. All cases were followed for one year after the original date of operation to create a database of readmissions after surgery. These data allowed for the determination of the 1-year incidence and type of reoperation, the timing of reoperation, the admitting diagnosis, hospital utilization, and total cost. Results. There were 164,050 THA performed on Medicare patients in the US in 2016. After surgery, there were 24,728 associated readmissions during the 1-year follow-up, or a readmission rate of 15.1%. There were 5,646 readmissions with a procedure performed on the hip; this represents 23% of the total 1-year readmissions after surgery, or a reoperation rate of 3.4%. Admission for reoperation was the most common reason for readmission following elective primary THA. When looking at reoperations, fracture was the most common (41.69%). 45% of reoperations occur within the first 30 days, 74% of reoperations occur within the first 90 days, and 26% of reoperations occur between days 90 and 360. For reoperations, a primary diagnosis of infection was associated with the highest average total cost ($104,024). Conclusions. Revision after THA is both a frequent occurance and expensive one. Fractures are the most common diagnoses that lead to revision, followed by dislocation. Increased focus to reduce complications such as fracture and dislocation would have the most beneficial impact on the patient, as well as on the healthcare system. For any tables or figures, please contact the authors directly