Aims. To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults. Methods. Using data from a multicentre randomized controlled trial (World Hip Trauma Evaluation 8 (WHiTE-8)) in the UK, a within-trial economic evaluation was conducted. Resource usage was measured over 120 days post randomization, and cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY), gained from the UK NHS and personal social services (PSS) perspective in the base-case analysis. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that high-dose, dual-antibiotic cement had a significantly higher mean cost (£224 (95% confidence interval (CI) -408 to 855)) and almost the same QALYs (0.001 (95% CI -0.002 to 0.003)) relative to single-antibiotic cement from the UK NHS and PSS perspective. The probability of the high-dose, dual-antibiotic cement being cost-effective was less than 0.3 at alternative cost-effectiveness thresholds, and its net monetary benefit was negative. This finding remained robust in the sensitivity analyses. Conclusion. This study shows that high-dose, dual-antibiotic cement is unlikely to be cost-effective compared to single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults. Cite this article: Bone Joint J 2023;105-B(10):1070–1077

Aims. The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years. Methods. This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs). Results. A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83). Conclusion. In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127–133

Aims. Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. Methods. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. Results. In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. Conclusion. The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients. Cite this article: Bone Jt Open 2022;3(9):710–715

Aims. The aim of this study was to compare the functional and radiological outcomes in patients with a displaced fracture of the hip who were treated with a cemented or a cementless femoral stem. Patients and Methods. A four-year follow-up of a randomized controlled study included 141 patients who underwent surgery for a displaced femoral neck fracture. Patients were randomized to receive either a cemented (n = 67) or a cementless (n = 74) stem at hemiarthroplasty (HA; n = 83) or total hip arthroplasty (THA; n = 58). Results. Early differences in functional outcome, assessed using the Harris Hip Score, the Short Musculoskeletal Functional Assessment score and EuroQol-5D, with better results in cemented group, deteriorated over time and there were no statistically significant differences at 48 months. Two (3%) patients in the cemented group and five (6.8%) in the cementless group underwent further surgery for a periprosthetic fracture. This difference was statistically significant (p = 0.4). No patient underwent further surgery for instability or infection between one and four years postoperatively. The mortality and the radiological outcomes were similar in both groups. Conclusion. Patients with a displaced femoral neck fracture treated with an arthroplasty using a cemented or cementless stem had good function and few complications up to four years postoperatively. However, due to the poor short-term functional outcomes in the cementless group, the findings do not support their routine use in the treatment of these elderly patients. Cite this article: Bone Joint J 2018;100-B:1087–93

National Institute of Clinical Excellence guidelines state that cemented stems with an Orthopaedic Data Evaluation Panel (ODEP) rating of > 3B should be used for hemiarthroplasty when treating an intracapsular fracture of the femoral neck. These recommendations are based on studies in which most, if not all stems, did not hold such a rating. . This case-control study compared the outcome of hemiarthroplasty using a cemented (Exeter) or uncemented (Corail) femoral stem. These are the two prostheses most commonly used in hip arthroplasty in the UK. Data were obtained from two centres; most patients had undergone hemiarthroplasty using a cemented Exeter stem (n = 292/412). Patients were matched for all factors that have been shown to influence mortality after an intracapsular fracture of the neck of the femur. Outcome measures included: complications, re-operations and mortality rates at two, seven, 30 and 365 days post-operatively. Comparable outcomes for the two stems were seen. . There were more intra-operative complications in the uncemented group (13% vs 0%), but the cemented group had a greater mortality in the early post-operative period (n = 6). There was no overall difference in the rate of re-operation (5%) or death (365 days: 26%) between the two groups at any time post-operatively. This study therefore supports the use of both cemented and uncemented stems of proven design, with an ODEP rating of 10A, in patients with an intracapsular fracture of the neck of the femur. Cite this article: Bone Joint J 2015;97-B:94–9

Aims. A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection. Patients and Methods. A quasi-randomised study of 848 patients with an intracapsular fracture of the hip was conducted in one large teaching hospital on two sites. All were treated with a hemiarthroplasty. A total of 448 patients received low dose single-antibiotic impregnated cement (control group) and 400 patients received high dose dual-antibiotic impregnated cement (intervention group). The primary outcome measure was deep SSI at one year after surgery. Results. The rate of deep SSI was 3.5% in the control group and 1.1% in the intervention group (p = 0.041; logistic regression adjusting for age and gender). The overall rate of non-infective surgical complications did not differ between the two groups (unadjusted chi-squared test; p > 0.999). Conclusion. The use of high dose dual-antibiotic impregnated cement in these patients significantly reduces the rate of SSI compared with standard low dose single antibiotic loaded bone cement. Cite this article: Bone Joint J 2016;98-B:1534–1541

The aim was to report operative complications, radiographic and patient-reported outcomes following lateral tibial plateau fracture fixation augmented with calcium phosphate cement (CPC). From 2007–2018, 187 patients (median age 57yrs [range 22–88], 63% female [n=118/187]) with a Schatzker II/III fracture were retrospectively identified. There were 103 (55%) ORIF and 84 (45%) percutaneous fixation procedures. Complications and radiographic outcomes were determined from outpatient records and radiographs. Long-term follow-up was via telephone interview. At a median of 6 months (range 0.1–138) postoperatively, complications included superficial peroneal nerve injury (0.5%, n=1/187), infection (6.4%, n=12/187), prominent metalwork (10.2%, n=19/187) and post-traumatic osteoarthritis (PTOA; 5.3%, n=10/187). The median postoperative medial proximal tibial angle was 89o (range 82–107) and posterior proximal tibial angle 82o (range 45–95). Three patients (1.6%) underwent debridement for infection and 27 (14.4%) required metalwork removal. Seven patients (4.2%) underwent total knee replacement for PTOA. Sixty percent of available patients (n=97/163) completed telephone follow-up at a median of 6yrs (range 1–13). The median Oxford Knee Score was 42 (range 3–48), Knee injury and Osteoarthritis Outcome Score 88 (range 10–100), EuroQol 5-Dimension score 0.812 (range −0.349–1.000) and Visual Analogue Scale 75 (range 10–100). There were no significant differences between ORIF and percutaneous fixation in patient-reported outcome (all p>0.05). Fixation augmented with CPC is safe and effective for lateral tibial plateau fractures, with a low complication rate and good long-term knee function and health-related quality of life. Percutaneous fixation offers a viable alternative to ORIF with no detriment to patient-reported outcome

Using data from the Norwegian Hip Fracture Register, 8639 cemented and 2477 uncemented primary hemiarthroplasties for displaced fractures of the femoral neck in patients aged > 70 years were included in a prospective observational study. A total of 218 re-operations were performed after cemented and 128 after uncemented procedures. Survival of the hemiarthroplasties was calculated using the Kaplan-Meier method and hazard rate ratios (HRR) for revision were calculated using Cox regression analyses. At five years the implant survival was 97% (95% confidence interval (CI) 97 to 97) for cemented and 91% (95% CI 87 to 94) for uncemented hemiarthroplasties. Uncemented hemiarthroplasties had a 2.1 times increased risk of revision compared with cemented prostheses (95% confidence interval 1.7 to 2.6, p < 0.001). The increased risk was mainly caused by revisions for peri-prosthetic fracture (HRR = 17), aseptic loosening (HRR = 17), haematoma formation (HRR = 5.3), superficial infection (HRR = 4.6) and dislocation (HRR = 1.8). More intra-operative complications, including intra-operative death, were reported for the cemented hemiarthroplasties. However, in a time-dependent analysis, the HRR for re-operation in both groups increased as follow-up increased. This study showed that the risk for revision was higher for uncemented than for cemented hemiarthroplasties

Introduction. Periprosthetic femur fractures are a serious complication after hip replacement surgery. In an aging population these fractures are becoming more and more common. Open reduction and plate osteosynthesis is one of the available treatment options. Objective. To investigate hip stem stability and cement mantle integrity under cyclic loading conditions after plate fixation with screws perforating the cement in the proximal fragment. Methods. Polished tapered hip stems were implanted in 16 biomechanical testing femora with Palacos cement (3rd generation technique) according to the manufacturer's recommendations. 8 testing bones were osteotomised distal to the stem representing the fracture group (Vancouver Type C). The osteotomy was fixed with a polyaxial locking plate, the other 8 specimens served as a control group. The specimens were tested in a biaxial material testing machine under axial compression (including adduction and torsion moments) for 100.000 cycles at physiological loads. Stem subsidence was measured in 3 planes with a stereoscopic image correlation system during the tests. Subsequently the sliced and crack dyed specimens were investigated microscopically for cement cracks. Results. In the control group no specimen failed during testing. There were no statistically significant differences in stem subsidence along the longitudinal axis (control group mean ± SD −15.4 ± 12.2 μm, fracture group −14.1 ± 13.1 μm). In the fracture group two specimens fractured through the most proximal screw hole after 74.000 and 80.000 cycles. Overall 15 out of 36 screws in the proximal fragment had direct stem contact. No cement cracks were detected in the sliced specimens in both groups. Conclusion. Drilling the cement mantle and placing screws in the cement did not increase stem subsidence under cyclic loading. No cracks or cement mantle failure were observed. Large screw diameters proximally weaken the lateral cortex resulting in tension failure of the bone. Plate fixation of a periprosthetic femoral fracture with a stable, cemented prosthesis does not lead to early cement mantle failure

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty. We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group. The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial

We used calcium-phosphate cement combined with minimal internal fixation to treat 49 fractures of the lateral tibial plateau. There were 25 split depression fractures, 22 pure depression fractures and two bicondylar fractures. Anatomical reduction was obtained in 38 fractures, satisfactory reduction in nine and imperfect reduction in two. Of 44 patients reviewed at one year, 33 were rated as having an excellent reduction. Functional outcome as measured by the Rasmussen score was good or excellent at six months in 92% (44/48) of patients and in 95% (42/44) at one year. Eight (16%) showed some loss of reduction of the plateau. In seven of these the loss of reduction was slight (< 3 mm) and no action was taken. One patient with a deep infection had gross loss of reduction and a poor functional outcome. Calcium-phosphate cement is a useful alternative to bone grafting for the treatment of fractures of the tibial plateau

Introduction:. The developing world often lacks the resources to effectively treat the most serious injuries, potentially resulting in severe complications of orthopaedic trauma, including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are now a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. Aims:. This project studied the effectiveness of locally made antibiotic beads, analysing their effectiveness after being gas sterilised, packaged and kept in storage. Methods:. Different antibiotic beads were manufactured locally using Simplex cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. Results:. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage, with slight fluctuations from week to week. Conclusion:. The four antibiotic beads manufactured using limited resources and in the austere environment were all effective in inhibiting bacterial growth. The growth of MRSA was inhibited by the antibiotic beads. Gas sterilisation or storage at room temperature for up to 42 days did not adversely deteriorate the efficacy of the beads. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition

Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. Methods and material. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. Results. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening). Discussion. Clinically, the three bearing types perform equally well at seven years, and there are few signs of impending failure for the stem. However, there are an alarmingly high proportion of cups showing signs of loosening. Two hips have been revised in the MOM group for aseptic loosening as opposed to none in the two other groups, which adds to the concern. The MOM articulation used in this study should be monitored closely for signs of aseptic loosening

Aims. The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty. Methods. The mean age of the patients was 85 years (58 to 102) and 273 (68%) were female. Follow-up was undertaken by a nurse who was blinded to the hemiarthroplasty that was used, at intervals for up to three years from surgery. The short-term follow-up of these patients at a mean of one year has previously been reported. Results. A total of 210 patients (52.5%) died within three years of surgery. One patient was lost to follow-up. Recovery of mobility was initially significantly better in those treated with a cemented hemiarthroplasty, although by three years after surgery this difference became statistically insignificant. The mortality was significantly lower in those treated with a cemented hemiarthroplasty (p = 0.029). There was no significant difference in pain scores, or in the incidence of implant-related complications or revision surgery, between the two groups. Conclusion. These results further support the use of a cemented hemiarthroplasty for the routine management of elderly patients with a displaced intracapsular fracture of the hip. Cite this article: Bone Joint J 2023;105-B(11):1196–1200

Aim of this study was to identify reoperation rates in patients with short oblique and transverse fractures around a well fixed cemented polished taper slip stem and to determine any associations with treatment failure. Retrospective cohort study of 31 patients with AO transverse or short oblique Vancouver B1 PFFs around THA (total hip arthroplasty) cemented taper slip stems: 12 male (39%); mean age 74±11.9 (range 44–91); mean BMI 28.5±1.4 (range 16–48); and median ASA 3. Patient journeys were assessed, re-interventions reviewed. The primary outcome measure was reoperation. Time from primary THA to fracture was 11.3±7.8yrs (0.5–26yrs). Primary surgical management was fixation in 27/31 and rTHA (revision total hip arthroplasty) in 4/31. 10 of 31 (32%) patients required reoperation, 9 within 2 years of fracture: 1 following rTHA and 8 following ORIF. The commonest mode of failure was non-union (n=6). No significant associations with reoperation requirement were identified. Kaplan-Meier free from reoperation was 67.4% (49.8–85.0 95% CI) at 2 years and this was unaffected by initial management with ORIF or rTHA (Log rank 0.898). Of those reoperated, 6/10 required multiple reoperations to obtain either bony union or a stable revision construct and 13% ultimately required proximal femoral endoprostheses. The relative risk of 1 year mortality was 1.6 (0.25 to 10.1 95%CI) among patients who required reoperation compared to those who did not. These are difficult fractures to manage, should not be underestimated and patients should be counselled that there is a 30% risk of reoperation and 20% of requiring multiple reoperations

Restoration of native Coronal Plane Alignment of the Knee (CPAK) phenotype is a strategy suggested to achieve better satisfaction. The aim of this study was to investigate the influence of changes in CPAK classification on patient-reported outcome measures (PROMs) and survivorship in a large cohort of manual mechanically aligned (MA) cemented TKAs. A retrospective analysis of 1062 consecutive cemented TKAs using MA philosophy at a single institution. Pre- and post-operative hip-knee-ankle radiographs were classified using the CPAK classification. Oxford Knee Score (OKS) and patient satisfaction (4-point-Likert scale) were collected prospectively. Implant survival data was obtained from our national arthroplasty database. We compared the outcomes of patients who maintained or changed their CPAK classification following TKA. Satisfaction was analysed using chi-square test, and OKS was analysed using Mann-Whitney test. Pre-operatively, most patients were CPAK type-I (38.8%). 85.5% of patients changed their CPAK type post-operatively, with CPAK type-V observed in 41.2% of these. Significantly better satisfaction (p=0.033) and OKS (p=0.021) were observed at one-year follow-up in patients who changed CPAK type, although the difference was below OKS minimally important clinical difference. There was no difference in satisfaction (p=0.73) and OKS (p=0.26) at one year between CPAK-V and non-V classifications. Post-operative CPAK type had no correlation with satisfaction and OKS. 12 TKAs (1.1%) were revised within 10 years (3 septic). In this large cohort of MA-TKA, excellent survivorship was observed at 10 years, with no demonstrable difference in outcome related to the final CPAK phenotype or change in phenotype

Aims. Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. Methods. The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group. Conclusion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72–78

The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval. 366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening. We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up

The aim of the study was to report the survival of open reduction and internal fixation (ORIF) of Vancouver B fractures associated with the Exeter Stem (ES) at a minimum of 5 years. This retrospective cohort study assessed 129 consecutive patients with Vancouver B type fractures treated with ORIF from 2008-2016 at a minimum of 5 years. Patient records were examined, and the following recorded: details of primary prosthesis, details of injury, Vancouver classification, details of operative management, complications, and requirement for reoperation. Data was analysed using SPSS. Survival analysis was undertaken using the endpoint ‘reoperation for any reason’. Mean age at fracture was 78.2 (SD10.6, 46-96) and 54 (43%) were female. Vancouver subclassifications were: 24% B1, 70.5% B2 and 5.5% B3. For all Vancouver B fractures, Kaplan Meier analysis demonstrated a 5 year survival free from reoperation of 88.8% (82.0-94.7 95%CI). Fourteen patients required reoperation, most commonly within the first year for non-union and plate fracture (5.4%). Five-year survival for any reoperation differed significantly according to fracture type (p=0.016) and was worst in B1s: B1 76.6% (61.3-91.9); B2 92.6% 986.9-98.3); and 100% of B3. Univariate analysis identified B1 type (p=0.008) and a transverse fracture pattern (p=0.003) to be significantly associated with the need for reoperation. Adopting a strategy of fixation of all Vancouver B fractures involving the ES where the fracture was anatomically reducible and the bone cement interface was well-fixed was associated with a 5 year survival, free from reoperation of 88.8%