Aims. The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. Methods. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed. Results. The BOne trauma and Soft-Tissue Injury classification system in total Hip arthroplasty (BOSTI Hip) grades osseous acetabular trauma and periarticular muscle damage during THA. The classification system has an interclass correlation coefficient of 0.90 (95% CI 0.86 to 0.93) for interobserver agreement and 0.89 (95% CI 0.84 to 0.93) for intraobserver agreement. RO THA was associated with improved BOSTI Hip scores (p = 0.002) and more pristine osseous surfaces in the anterior superior (p = 0.001) and posterior superior (p < 0.001) acetabular quadrants compared with CO THA. There were no differences between the groups in relation to injury to the gluteus medius (p = 0.084), obturator internus (p = 0.241), piriformis (p = 0.081), superior gamellus (p = 0.116), inferior gamellus (p = 0.132), quadratus femoris (p = 0.208), and vastus lateralis (p = 0.135), but overall combined muscle injury was reduced in RO THA compared with CO THA (p = 0.023). Discussion. The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. RO THA was associated with improved BOSTI Hip scores, more pristine osseous acetabular surfaces, and reduced combined periarticular muscle injury compared with CO THA. Further research is required to understand if these intraoperative findings translate to differences in clinical outcomes between the treatment groups. Cite this article: Bone Joint J 2024;106-B(9):898–906

Aims. The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks. Methods. The RHCC was developed with the help of a steering group and an invitation through the British Hip Society (BHS) to members to apply, forming an expert panel of 35. We ran a mixed-method modified Delphi process (three rounds of questionnaires and one virtual meeting). Round 1 consisted of identifying the factors that govern the decision-making and complexities, with weighting given to factors considered most important by experts. Participants were asked to identify classification systems where relevant. Rounds 2 and 3 focused on grouping each factor into H1, H2, or H3, creating a hierarchy of complexity. This was followed by a virtual meeting in an attempt to achieve consensus on the factors which had not achieved consensus in preceding rounds. Results. The expert group achieved strong consensus in 32 out of 36 factors following the Delphi process. The RHCC used the existing Paprosky (acetabulum and femur), Unified Classification System, and American Society of Anesthesiologists (ASA) classification systems. Patients with ASA grade III/IV are recognized with a qualifier of an asterisk added to the final classification. The classification has good intraobserver and interobserver reliability with Kappa values of 0.88 to 0.92 and 0.77 to 0.85, respectively. Conclusion. The RHCC has been developed through a modified Delphi technique. RHCC will provide a framework to allow discussion of complex cases as part of a local or regional hip revision MDT. We believe that adoption of the RHCC will provide a comprehensive and reproducible method to describe each patient’s case with regard to surgical complexity, in addition to medical comorbidities that may influence their management. Cite this article: Bone Jt Open 2022;3(5):423–431

The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC. Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result. All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process. Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%. Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441. Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773). Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement. This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases

Aims. Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology. Methods. This prospective, multicentre study evaluated 3,777 consecutive patients undergoing THA by three surgeons, between January 2014 and December 2019. They were categorized using The Hip-Spine Classification system: group 1 with normal spinal alignment; group 2 with a flatback deformity, group 2A with normal spinal mobility, and group 2B with a stiff spine. Flatback deformity was defined by a pelvic incidence minus lumbar lordosis of > 10°, and spinal stiffness was defined by < 10° change in sacral slope from standing to seated. Each category determined a patient-specific component positioning. Survivorship free of dislocation was recorded and spinopelvic measurements were compared for reliability using intraclass correlation coefficient. Results. A total of 2,081 patients met the inclusion criteria. There were 987 group 1A, 232 group 1B, 715 group 2A, and 147 group 2B patients. A total of 70 patients had a lumbar fusion, most had L4-5 (16; 23%) or L4-S1 (12; 17%) fusions; 51 patients (73%) had one or two levels fused, and 19 (27%) had > three levels fused. Dual mobility (DM) components were used in 166 patients (8%), including all of those in group 2B and with > three level fusions. Survivorship free of dislocation at five years was 99.2% with a 0.8% dislocation rate. The correlation coefficient was 0.83 (95% confidence interval 0.89 to 0.91). Conclusion. This is the largest series in the literature evaluating the relationship between hip-spine pathology and dislocation after THA, and guiding appropriate treatment. The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. Cite this article: Bone Joint J 2021;103-B(7 Supple B):17–24

Objectives. Using a simple classification method, we aimed to estimate the collapse rate due to osteonecrosis of the femoral head (ONFH) in order to develop treatment guidelines for joint-preserving surgeries. Methods. We retrospectively analyzed 505 hips from 310 patients (141 men, 169 women; mean age 45.5 years . (sd. 14.9; 15 to 86)) diagnosed with ONFH and classified them using the Japanese Investigation Committee (JIC) classification. The JIC system includes four visualized types based on the location and size of osteonecrotic lesions on weightbearing surfaces (types A, B, C1, and C2) and the stage of ONFH. The collapse rate due to ONFH was calculated using Kaplan–Meier survival analysis, with radiological collapse/arthroplasty as endpoints. Results. Bilateral cases accounted for 390 hips, while unilateral cases accounted for 115. According to the JIC types, 21 hips were type A, 34 were type B, 173 were type C1, and 277 were type C2. At initial diagnosis, 238/505 hips (47.0%) had already collapsed. Further, the cumulative survival rate was analyzed in 212 precollapsed hips, and the two-year and five-year collapse rates were found to be 0% and 0%, 7.9% and 7.9%, 23.2% and 36.6%, and 57.8% and 84.8% for types A, B, C1, and C2, respectively. Conclusion. Type A ONFH needs no further treatment, but precollapse type C2 ONFH warrants immediate treatment with joint-preserving surgery. Considering the high collapse rate, our study results justify the importance of early diagnosis and intervention in asymptomatic patients with type C2 ONFH. Cite this article: Y. Kuroda, T. Tanaka, T. Miyagawa, T. Kawai, K. Goto, S. Tanaka, S. Matsuda, H. Akiyama. Classification of osteonecrosis of the femoral head: Who should have surgery?. Bone Joint Res 2019;8:451–458. DOI: 10.1302/2046-3758.810.BJR-2019-0022.R1

Aims. Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system. Methods. A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected. Results. A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015). Conclusion. There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable. Cite this article: Bone Joint J 2023;105-B(7):751–759

Aims. The aim of the current study was to assess the reliability of the Ottawa classification for symptomatic acetabular dysplasia. Methods. In all, 134 consecutive hips that underwent periacetabular osteotomy were categorized using a validated software (Hip2Norm) into four categories of normal, lateral/global, anterior, or posterior. A total of 74 cases were selected for reliability analysis, and these included 44 dysplastic and 30 normal hips. A group of six blinded fellowship-trained raters, provided with the classification system, looked at these radiographs at two separate timepoints to classify the hips using standard radiological measurements. Thereafter, a consensus meeting was held where a modified flow diagram was devised, before a third reading by four raters using a separate set of 74 radiographs took place. Results. Intrarater results per surgeon between Time 1 and Time 2 showed substantial to almost perfect agreement among the raters (κappa = 0.416 to 0.873). With respect to inter-rater reliability, at Time 1 and Time 2 there was substantial agreement overall between all surgeons (Time 1 κappa = 0.619; Time 2 κappa = 0.623). Posterior and anterior rating categories had moderate and fair agreement at Time 1 (posterior κappa = 0.557; anterior κappa = 0.438) and Time 2 (posterior κappa = 0.506; anterior κappa = 0.250), respectively. At Time 3, overall reliability (κappa = 0.687) and posterior and anterior reliability (posterior κappa = 0.579; anterior κappa = 0.521) improved from Time 1 and Time 2. Conclusion. The Ottawa classification system provides a reliable way to identify three categories of acetabular dysplasia that are well-aligned with surgical management. The term ‘borderline dysplasia’ should no longer be used. Cite this article: Bone Joint Res. 2020;9(5):242–249

Aims. This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems. Methods. Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss’ kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs. Results. Interobserver reliability percentage agreement was 58.5% and the overall kappa value was 0.442 (moderate agreement). Lowest kappa values were seen for type B fractures (0.095 to 0.360). The mean intraobserver reliability kappa value was 0.672 (0.447 to 0.867), indicating substantial agreement. Validity percentage agreement was 65.7% and the mean kappa value was 0.300 (0.160 to 0.4400) indicating only fair agreement. Conclusion. This study demonstrates that the UCS is unsatisfactory for the classification of PFFs around PTS stems, and that it has considerably lower reliability and validity than previously described for other stem types. Radiological PTS stem loosening in the presence of PFF is poorly defined and formal intraoperative testing of stem stability is recommended. Cite this article: Bone Joint J 2021;103-B(8):1339–1344

Aims. The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. Methods. A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m. 2. are considered “high risk” by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode. Results. In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were “high risk”. Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202. Conclusion. Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units. Cite this article: Bone Jt Open 2023;4(8):559–566

Background. Total hip arthroplasty (THA) in patients with congenital dysplasia of the hip (CDH) is complex and challenging. The Crowe and Hartofilakidis classification systems are the most commonly used. However, neither encompasses the whole spectrum of disease and deformity and therefore does not guide modern surgical options. We present a new classification system which aims to guide surgical strategy by focusing on the three main areas of disease and deformity: Cup defect; De-rotation of femoral neck ante-version; Height of femoral subluxation. Each component is graded from 1–3 based on the severity of deformity and the potential surgical strategy required (with 3 being the most severe). A total numerical score will reflect the overall degree of difficulty which may be used when assessing surgical outcomes. The aim of this study is to assess the reliability of this new adult CDH classification system in the setting of THA. Study design and Methods. A sample size calculation showed 28 evaluations were required to reach a power of 85% (based on a kappa value of 0.4). The anterior-posterior pelvis and lateral hip radiographs of 30 hips, in 26 patients were evaluated by three Consultant Orthopaedic Surgeons using the classification detailed in table 1. A second evaluation, with the case order randomised, was performed after a minimum period of 1month. Randolph's free multi-rater Kappa co-efficient was used to assess for inter and intra- observer reliability and 95% confidence intervals were calculated. Results. The results of the Inter and intra–observer reliability for each classification component and for each rater respectively are shown in table 2 and 3. Conclusions. In comparison with other studies our reliability results were poorer when compared to the Hartofilakidis and Crowe classification systems. It was reported by the participants that our system enabled a more logical breakdown of the component deformities to address when performing THA in these hips. As with the Paprosky system for revision hip arthroplasty, this X-ray classification is intended as a practical pre-op guide to planning for all eventualities. Limitations due to level of observer experience and finer intra-operative judgements may alter the final result, but the essence is to understand the anatomical pitfalls enabling appropriate surgical planning and a total score against which to judge outcomes. For any figures or tables, please contact the authors directly

Introduction. During revision total hip arthroplasty, successful treatment of acetabular bone loss with an associated chronic pelvic discontinuity is dependent upon the remaining bone stock, stability of the construct, potential for biologic fixation, and healing of the discontinuity. Several techniques have been described for the treatment of this clinical entity; the authors recommend the use of acetabular distraction technique in conjunction with a jumbo cup with or without augments. The authors recently evaluated the minimum two-year follow-up of acetabular distraction technique for the treatment of chronic pelvic discontinuity. In the process, a chronic pelvic discontinuity classification was created based on the type of reconstruction required. The purpose of this study is to introduce the initial observations of this novel classification system. Methods. Patients from two academic institutions undergoing acetabular distraction for chronic pelvic discontinuity were identified between January 2002 and December 2013 with minimum 2-year follow-up. Radiographs at latest follow-up were compared to serial radiographs from the index surgery. Data was collected by chart review in accordance with institutional IRB protocol from both institutions. Results. A cohort of 32 patients had minimum 2-year (range, 2.1–13.3 years) follow-up. Mean patient age was 67 years (range, 44–86) and 87% were female. All patients had a chronic pelvic discontinuity with the following bone loss patterns: 7 (22%) type IIC, 5 (15%) type IIIA and 20 (63%) type IIIB. At time of final follow-up, radiographs demonstrated 22 of 32 patients (69%) had evidence of a healed discontinuity. Chronic Pelvic Discontinuity Classification. The classification mirrors the Paprosky classification and requires a more complex reconstruction with each progressive type. For the 20 patients with a type IIIB acetabular bone loss pattern, the new classification was applied. The distribution of classification types was as follows: type I 6 (30%); type II 5 (25%); type IIIA 4 (20%); type IIIB 5 (25%); and type IV 0. Overall, 70% (14) patients required the use of an augment for acetabular reconstruction. Conclusions. Acetabular distraction has been established as an effective method by which to treat chronic pelvic discontinuity. The new classification helps to determine the complexity of reconstruction required for each discontinuity, especially when assessing the most severe acetabular defects (Paprosky IIIB). The authors advocate acetabular distraction with a jumbo cup and modular porous metal augments as the preferred treatment for acetabular bone loss with associated chronic pelvic discontinuity. According to the new classification, the likelihood of utilizing augment(s) increases with severity of bone loss. Future studies are required to validate this new chronic pelvic discontinuity classification

Background. Hip dysplasia has traditionally been classified based on the lateral center edge angle (LCEA). A recent meta-analysis demonstrated no definite consensus and a significant heterogeneity in LCEA values used in various studies to define hip dysplasia and borderline dysplasia. To overcome the shortcomings of classifying hip dysplasia based on just LCEA, a comprehensive classification for adult acetabular dysplasia (CCAD) was proposed to classify symptomatic hips into three discrete prototypical patterns of hip instability; lateral/global, anterior, or posterior. The purpose of this study was to assess the reliability of this recently published CCAD. Methods. One hundred thirty-four consecutive hips that underwent a PAO were categorized using a validated software (Hip2Norm) into four categories of normal, lateral/global, anterior or posterior. Based on the prevalence of individual dysplasia and using KappaSize R package version 1.1, seventy-four cases were necessary for reliability analysis: 44 dysplastic and 30 normal hips were randomly selected. Five surgeons (3 fellowship trained in hip preservation) did a first reading (Time 1) to classify the hips, followed by four raters for a second reading (Time 2) minimum two weeks apart. Thereafter, a consensus meeting was held where a simplified flow diagram was devised before a third reading by four raters using a separate set of 74 radiographs took place. Results. There was substantial and almost perfect intra-rater agreement for 4 surgeons between Time 1 and Time 2. At time 1 and time 2, there was substantial agreement overall between all surgeons; however, posterior and anterior rating categories had moderate and fair agreement at time 1 and time 2, respectively. At time 3, overall reliability and posterior and anterior rating improved from Time 1 and Time 2. Conclusion. This comprehensive classification system provides a reliable way to identify three categories of acetabular dysplasia that are well-aligned with surgical management. The term borderline dysplasia should no longer be used

Introduction. Undersizing of an uncemented femoral stem is a post-operative description of a radiograph with unclear clinical importance. It may not always translate into a suboptimal clinical outcome. Aim. To describe a novel classification system of undersizing in a fully hydroxyapatite coated femoral implant, assess if it could be reliably reported between observers, and describe a simple way to assess the degree of undersizing on an AP radiograph. Methods. A retrospective review of 1000 consecutive total hip arthroplasties was conducted. Two investigators reviewed post-operative radiographs independently for stem undersizing. The data was tested for inter and intra-observer agreement using the Kappa method. Results. Undersizing was classified as:. Varus - Stem in contact proximally with medial calcar, and distally with lateral cortex. Valgus - Stem in contact proximally with lateral cortex, and distally with medial cortex. Uniform - Continuous margin around the stem of at least one-half tip width of the stem throughout. Champagne flute - Distal stem fills the narrow diaphysis with insufficient bony contact at the wide metaphysis. If varus or valgus undersizing was present we described the formation of two triangles of excess cancellous space around the implant, each having overlapping apices signifying undersizing by at least two sizes. 32% of the stems were undersized with Kappa demonstrating very good (89%) to good (86%) inter and intra observer agreement respectively. 50% of undersized stems were uniformly undersized, 36% were varus, 6% valgus, and 8% were in a champagne fluted shaped femur. A higher percentage of the lateralised (KLA) stems were undersized compared to other neck configurations (40%). 54% of these were varus undersized and this increased the offset up to 2cm. Conclusion. We describe a classification system for undersizing in hip arthroplasty. KLA stems have an increased tendency to be undersized in varus, thereby increasing the overall offset

The Vancouver classification has been shown by its developers to be a valid and reliable method for categorising the configuration of periprosthetic proximal femoral fractures and for planning their management. We have re-validated this classification system independently using the radiographs of 30 patients with periprosthetic fractures. These were reviewed by six experienced consultant orthopaedic surgeons, six trainee surgeons and six medical students in order to assess intra- and interobserver reliability and reproducibility. Each observer read the radiographs on two separate occasions. The results were subjected to weighted kappa statistical analysis. The respective kappa values for interobserver agreement were 0.72 and 0.74 for consultants, 0.68 and 0.70 for trainees on the first and second readings of the radiographs and 0.61 for medical students. The intra-observer agreement for the consultants was 0.64 and 0.67, for the trainees 0.61 and 0.64, and for the medical students 0.59 and 0.60 for the first and second readings, respectively. The validity of the classification was studied by comparing the pre-operative radiological findings within B subgroups with the operative findings. This revealed agreement for 77% of these type-B fractures, with a kappa value of 0.67. Our data confirm the reliability and reproducibility of this classification system in a European setting and for inexperienced staff. This is a reliable system which can be used by non-experts, between centres and across continents

Introduction. The Vancouver Classification System presents a systematic approach to classification of periprosthetic fractures of the proximal femur (PFPFs) that has been validated in previous studies. However, with the introduction of tapered fluted stems and cable plates since the introduction of the Vancouver System, the connection between fracture class and the preferred method of treatment is often unclear. The present study was undertaken to identify fracture patterns surrounding contemporary femoral stems and the relationship between the current method of treatment and the Vancouver Class of the periprosthetic fracture. Methods. Three experienced joint surgeons collected plain radiographs (AP and lateral) and CT/MR scans (n=40) from 72 cases of Vancouver A or B periprosthetic fractures performed over the period 2016–2018. We identified the mode of primary stem fixation and the Vancouver grade of the fracture (A, B1, B2 or B3). Two independent investigators examined all imaging studies and the intraoperative records and recorded: (i) and the location and distribution of the fracture surfaces, and (ii) the presence of incomplete cortical fractures that had initiated within the femoral cortex without completing propagation and (iii) the method of operative treatment. These data were analyzed to examine the incidence of fractures within more than one femoral zone and differences in the fracture patterns corresponding to each Vancouver class. Results. One fifth (21%) of fractures were Type A with the remainder consisting predominantly of Type B2 (39%), with approximately equal proportions of Type B1 (22%) and B3 (18%) fractures. In almost half of Type B2 fractures (a loose femoral stem and a fracture adjacent to the prosthesis), fractures were also present within the metaphysis (ie. Type A+B). In the presence of a cementless femoral stem, fractures often occurred adjacent to the uncoated surface of the stem distal to the proximal ingrowth surface. Type B2 and B3 femurs had similar fracture patterns and degrees of comminution, though their method of treatment differed significantly. Incomplete fractures were identified in every Vancouver class (entire sample: 22%), especially in association with loose stems in poor quality bone (Type B3; 38% of cases). Conclusions. Approximately two-thirds of periprosthetic femoral fractures involve a loose femoral component (ie Types B2 and B3), though bone quality impacts operative treatment. In cementless stems, Vancouver Type B fractures often occur in the unbonded diaphysis between the distal edge of the ingrowth surface and immediately below the stem tip. Incomplete fractures are present in a surprising proportion of cases, suggesting that careful examination of imaging studies is needed to prevent fracture propagation due to inadequate fixation. CT scans are a useful adjunct to supplement plain radiographs. For any tables or figures, please contact the authors directly

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement

Our study evaluated the reliability of the Crowe and Hartofilakidis classification systems for developmental dysplasia of the hip in adults. The anteroposterior radiographs of the pelvis of 145 patients with 209 osteoarthritic hips were examined twice by three experienced hip surgeons from three European countries and the abnormal hips were rated using both classifications. The inter- and intra-observer agreement was calculated. Interobserver reliability was evaluated using weighted and unweighted kappa coefficients and for the Crowe classification, among the three pairs there was a minimum kappa coefficient with linear weighting of 0.90 for observers A and C and a maximum kappa coefficient of 0.92 for observers B and C. For the Hartofilakidis classification, the minimum kappa value was 0.85 for observers A and B, and the maximum value was 0.93 for observers B and C. With regard to intra-observer reliability, the kappa coefficients with linear weighting between the two evaluations of the same observer ranged between 0.86 and 0.95 for the Crowe classification and between 0.80 and 0.93 for the Hartofilakidis classification. The reliability of both systems was substantial to almost perfect both for serial measurements by individual readers and between different readers, although the information offered was dissimilar

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification

Introduction. The prevalence of adverse reactions to metal debris (ARMD) associated with metal on metal (MoM) hip arthroplasty has been reported to be as high as 69%. Such findings promoted the development of metal-artefact reducing sequence (MARS)-magnetic resonance imaging (MRI) classifications, with the aim of stratifying soft lesions by severity of disease. The Modified Oxford Classification is a straightforward system that has been shown to correlate with disease progression. Methods. The aim of this study was to test the reliability of this classification between observers. Seven observers were recruited, all with a musculoskeletal background. Using the PACS image analysis system, 20 MARS-MRI scans were provided for interpretation. Observers reviewed these scans in random order at two separate intervals over the course of five weeks. They classified them according to the Modified Oxford Classification as: ‘normal’, ‘trochanteric fluid, ‘effusion’, ‘ARMD type 1’, ‘ARMD type 2’ and ‘ARMD type 3’. Results. Statistical tests using kappa co-efficients were performed to get intra and inter observer reliabilities. Our results were compared against the grading system proposed by Landis and Koch. Our inter-rater agreement was 0.61. This is considered substantial agreement. Our intra observer scores ranged for 0.57 to 1.00 indicating consistency between the observers as individuals and as a group. Conclusion. The modified oxford classification is simple and easy to remember and has substantial reliability. It is proving to be effective in communicating, classifying and providing an understanding of disease progression

Background. Sub-trochanteric fractures are challenging to treat due to various anatomical and biomechanical factors. High tensile forces contribute to the challenge of fracture reduction. Intramedullary nailing has become the treatment of choice. If anatomical reduction is not achieved, any mal-alignment will predispose to implant failure. Open reduction with cerclage wires can add to construct stability and improve the quality of reduction. There is no consensus or classification to guide surgeons on when to perform open reduction, which is often performed intra-operatively when closed reduction fails often with no planning. This can lead to intraoperative delays as theatre staff would not have prepared the correct equipment necessary for open reduction. Objectives. The purpose of this study was to assess outcomes of closed and open reduction of traumatic sub-trochanteric fractures treated with intramedullary nailing and to propose a new classification system to dictate management. Methods. After a review of current classification systems, a 3-tier classification was proposed (Type 1, 2 and 3). Type 1 indicated a transverse fracture, Type 2 was a spiral fracture with an intact posterior and medial wall and a Type 3 fracture were fractures with no posterior and/or medial walls. Over a two-year period (2013–2015), patients with sub trochanteric fractures were classified into Type 1, 2 or 3 injuries based on radiographic appearances by two senior clinicians. Patients with Type 3 injuries were divided into two groups based on whether they were treated with open or closed reduction. A clinical and radiographic review was performed. The primary outcome measure was the incidence of implant failure, whereas secondary outcome measures were related to fracture reduction. Statistical analysis was performed using GraphPad Prism Version 6 (GraphPad Software Inc. California, USA). Fisher's exact test was used for independent categorical data and Mann–U Whitney for continuous nonparametric data. Statistical significance was set at p<0.05. Results. 75 patients had intramedullary nailing for subtrochanteric fractures over the study period with a mean age of 82.6 years. There were 48 patients who had a Type 3 fracture pattern with a deficient medial and/or posterior wall. Reduction was achieved open with cerclage wires in 42% of patients (n=20 and closed in 58% (n=28). Overall there were a total of 18 (37.5%) major complications. In patients treated with closed reduction, 9 patients suffered mechanical complications (6 distal locking screw failures, 3 lag screw cut outs). There was a significantly increased risk of implant failure in patients treated with closed reduction compared to open reduction (p=0.006). No cases with cerclage wire had implant failure. Open reduction with cerclage wires improved the quality of reduction (p=0.0001) compared with closed reduction. There was no significant increase in operating time in patients treated with cerclage wires (p=0.4334). Conclusions. Open reduction with cerclage wires should be considered in patients with Type 3 sub-trochanteric fractures as it has shown to significantly reduce the risk of implant failure and improve the quality of reduction with no significant increase in operating time