Objectives. The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?. Methods. We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. Results. We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. Conclusions. Further observational research should be conducted to define the population of interest before future interventional studies are performed. Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1

Aims

Modular dual mobility (MDM) acetabular components are often used with the aim of reducing the risk of dislocation in revision total hip arthroplasty (THA). There is, however, little information in the literature about its use in this context. The aim of this study, therefore, was to evaluate the outcomes in a cohort of patients in whom MDM components were used at revision THA, with a mean follow-up of more than five years.

Aims

The aim of this systematic review was to report the rate of dislocation following the use of dual mobility (DM) acetabular components in primary and revision total hip arthroplasty (THA).

Aims. One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. Methods. In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. Results. Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years’ time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. Conclusion. Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678–1685

Dual mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a known rare complication of these implants and has reportedly decreased with modern implants. The purpose of this paper is to report the diagnosis and treatment of modern DM IPD. 1453 DM components were implanted between 2010 and 2021. 695 in primary and 758 in revision THA. 49 hips sustained a dislocation of the large head and 5 sustained an IPD at presentation. 6 additional IPD occurred at the time of reduction of large head. The average age was 64, 54% were female and the mean follow-up was three years. Of the 11 IPD, 8 had a history of instability, 5 had abductor insufficiency, 4 had prior lumbar fusion, and 3 were conversions from fracture. The overall IPD incidence was 0.76%. Ten of the 11 DM IPD were missed at initial presentation or at the time of reduction, and all were discharged with presumed reduction. The mean time from IPD to surgical treatment was 3 weeks. One patient died with an IPD at 5 months. A DM head was reimplanted in six, two underwent revision of the acetabular component with exchange of DM head, and four were revised to a constrained liner. The re-revision rate was 55% at a mean 1.8 years. None of the patients who underwent cup revision required subsequent re-revision while half of the constrained liners and exchange of DM heads required re-revision. The overall rate of DM dislocation or IPD is low. It is critical to identify an IPD on radiographs as it was almost universally missed at presentation or when it occurred iatrogenically. For patients presenting with IPD, the surgeon should consider acetabular revision and conversion to a constrained liner or a larger DM, with special attention to removing impinging structures that could increase the risk of re-dislocation

The increased torque required to dislocate dual mobility (DM) components may increase peri-prosthetic femoral fracture (PPF) risk. Current literature often relies on revision as an endpoint and may underestimate PPF. This study aims to review PPF rate, risks and treatment following primary DM implantation. Prospective cohort study of 549 patients following primary DM total hip arthroplasty (THA) between 2013 and 2021. Collected data included demographics, indication for surgery, cortical index and PPF. 549 patients were identified with primary DM THA. Mean age was 73 years (26–96). 446 (81.2%) patients had their index surgery following hip fracture. 18 patients (3.27%) sustained a PPF. Cumulative PPF rate was 1.5% at 1-year, 2.2% at 5-years and 3.27% overall. PPF was higher in patients undergoing surgery following hip fracture (4%) vs. other indications (1%). OR 4.04 (95% CI:0.53, 30.72), p=0.219. Mean cortical index was lower in patients with PPF 0.4 (95% CI:0.36, 0.45) compared to those without 0.46 (95% CI:0.45, 0.46) p=0.029. Treatment for PPF included 10 (55.6%) open reduction internal fixation (ORIF), 7 (38.9%) revision THA and 1 conservatively managed. PPF rate following DM use is higher in our cohort than published rates. Our rates are comparable to some papers when subgroup analysis of older patients and cemented taper slip stems are considered. PPF risk with DM may be increased in patients undergoing surgery after hip fracture or with a lower cortical index preoperatively. Over half of PPF were managed with ORIF and may mask PPF risk studies that report using revision as an endpoint

Aims. To report our experience with trunnion corrosion following metal-on-polyethylene total hip arthroplasty, in particular to report the spectrum of presentation and determine the mean time to presentation. Patients and Methods. We report the presenting symptoms and signs, intraoperative findings, and early results and complications of operative treatment in nine patients with a mean age of 74 years (60 to 86). The onset of symptoms was at a mean of seven years (3 to 18) after index surgery. Results. Patients presented with a variety of symptoms including pain, limp and rash. The preoperative mean serum cobalt level was 7.1 ppb (2.2 to 12.8) and mean serum chromium level was 2.2 ppb (0.5 to 5.2). Metal artifact reduction sequence (MARS) MRI showed fluid collection and possible pseudotumour formation in five hips, fluid collection in two hips, and synovitis/debris in one hip, with no MRI in one patient. Acetabular revision was performed in three patients, six patients underwent liner and head exchange only. The postoperative metal levels decreased in all patients: mean cobalt 0.5 ppb (0 to 1.8) and mean chromium 0.9 ppb (0 to 2.6) at a mean of five months (3 to 8) postoperatively. Seven patients had good pain relief and no complications at one year. There were two major complications requiring reoperation: acute infection at six weeks, for which the patient required two-stage reimplantation; and recurrent dislocation, for which the patient was revised to a dual mobility component. Conclusion. Trunnion corrosion in metal-on-polyethylene THA has a range of presenting symptoms, and may present later than previously described. A high index of suspicion is warranted, and serum cobalt and chromium levels are recommended for diagnosis. Patients should be counselled about possible postoperative complications. Cite this article: Bone Joint J 2018;100-B:898–902

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

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making

Trunnion corrosion in metal-on-polyethylene THA is poorly understood, with multifactorial etiology, and the patients present with “hip pain”. We analysed the presenting symptoms and signs, intraoperative findings and the early results and complications of operative treatment. One surgeon treated 9 patients (6 male, 3 female), mean age 74 years, with the onset of symptoms at a mean of 7 years (range 3–18) after index surgery. The taper size was 12/14 in seven, 14/16 in one, and 6 degree in one hip. The preoperative mean cobalt level was 7.1 ppb (range, 2.2–12.8) and mean chromium level was 2.2 ppb (range, 0.5–5.2). MARS MRI showed fluid collection and pseudotumor in 5, fluid collection only in two, and synovitis/debris in one hip. In one patient, there was no preoperative MRI. There were a myriad of clinical presentations: thigh rash alone in one; diffuse leg pain and hip rash in one; acute pseudo-sepsis in one; iliopsoas tendinitis and diffuse rash in one; trochanteric bursitis in one; groin pain only in one; thigh-buttock pain in two; and diffuse hip pain and limp in one patient. Intraoperatively, 6 patients had liner and ceramic (or oxidized zirconium) head exchange only. Three patients had concurrent acetabular revision: one for broken locking mechanism; one because liner was unavailable, and one had acetabular loosening. The postoperative metal levels decreased in all patients: mean cobalt 0.5 ppb (range, 0–1.8) and mean chromium 0.9 ppb (range, 0–2.6). Seven patients had good pain relief and no complications. There were two major complications requiring reoperation: acute infection at 6 weeks and patient required 2-stage reimplantation; and second patient had recurrent dislocation and was revised to a dual mobility component. Trunnion corrosion in metal-on-polyethylene THA has several clinical presentations, including local skin rash, iliopsoas tendinitis, and other limb dysfunction. There should be a high index of suspicion and serum cobalt/chromium levels are recommended for diagnosis. The patients should be counseled about possible postoperative complications

Instability continues to be a troublesome complication after THA and has been reported to be the main indication for revision in the United States, accounting for 22.5% of revisions. Risk factors associated with dislocation include: age of 75 years or older, body mass index (BMI) of 30 kg/m2 or greater, alcohol abuse, and neuro-degenerative diseases such as multiple sclerosis or Parkinson's disease. Dual-mobility articulations have become an increasingly popular option for these “at risk” primary THAs. Few studies have assessed their use in this complex patient population. The purpose of this study was to assess dislocation rate, radiographic outcomes and complications of the dual-mobility articulation in the setting of primary THA for patients at high risk for dislocation at a minimum follow up of 2 years. We retrospectively reviewed 151 dual mobility acetabular components, that had been performed using a single design (ADM Stryker, Mahwah, NJ) between 2010 and 2014 at a single institution by a single surgeon. The mean age at time of index surgery was 82 years (range, 73–95), 114 patients were female, and mean BMI was 26.2 kg/m2 (range, 16.1–60.9). Dislocation rate and complications associated with dual mobility cups were reviewed, along with the radiographic outcomes after an average follow-up period of 3.6 years (range, 1.9–6.1 years). The indication for hip replacement was osteoarthritis in all cases. We had one traumatic dislocation which required component revision after intraprosthetic dislocation following an attempt of closed reduction. There were no further dislocations in this cohort. No progressive radiolucencies or component positional changes were seen on radiographic assessment. At short-term follow-up dual mobility provides a stable reconstruction in patients at high risk of dislocation with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions

Aims

Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.

Aims

The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

Aims

This combined clinical and in vitro study aimed to determine the incidence of liner malseating in modular dual mobility (MDM) constructs in primary total hip arthroplasties (THAs) from a large volume arthroplasty centre, and determine whether malseating increases the potential for fretting and corrosion at the modular metal interface in malseated MDM constructs using a simulated corrosion chamber.

Aims

Dual mobility (DM) implants have been shown to reduce the dislocation rate after total hip arthroplasty (THA), but there remain concerns about the use of cobalt chrome liners inserted into titanium shells. The aim of this study was to assess the clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) at mid-term follow-up in young, active patients receiving a modular DM THA.

Aims

The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA.

Aims

We previously reported the long-term results of the cementless Duraloc-Profile total hip arthroplasty (THA) system in a 12- to 15-year follow-up study. In this paper, we provide an update on the clinical and radiological results of a previously reported cohort of patients at 23 to 26 years´ follow-up.

Objectives

The primary objective of this study was to compare accuracy in restoring the native centre of hip rotation in patients undergoing conventional manual total hip arthroplasty (THA) versus robotic-arm assisted THA. Secondary objectives were to determine differences between these treatment techniques for THA in achieving the planned combined offset, component inclination, component version, and leg-length correction.

Aims

Few reconstructive techniques are available for patients requiring complex acetabular revisions such as those involving Paprosky type 2C, 3A and 3B deficiencies and pelvic discontinuity. Our aim was to describe the development of the patient specific Triflange acetabular component for use in these patients, the surgical technique and mid-term results. We include a description of the pre-operative CT scanning, the construction of a model, operative planning, and surgical technique. All implants were coated with porous plasma spray and hydroxyapatite if desired.

Aims

Posterior tilt of the pelvis with sitting provides biological acetabular opening. Our goal was to study the post-operative interaction of skeletal mobility and sagittal acetabular component position.