Metal-on-metal hip resurfacing prostheses are a relatively recent intervention for relieving the symptoms of common musculoskeletal diseases such as osteoarthritis. While some short term clinical studies have offered positive results, in a minority of cases there is a recognised issue of femoral fracture, which commonly occurs in the first few months following the operation. This problem has been explained by a surgeon's learning curve and notching of the femur but, to date, studies of explanted early fracture components have been limited.

Tribological analysis was carried out on fourteen retrieved femoral components of which twelve were revised after femoral fracture and two for avascular necrosis (AVN). Eight samples were Durom (Zimmer, Indiana, USA) devices and six were Articular Surface Replacements (ASR, DePuy, Leeds, United Kingdom). One AVN retrieval was a Durom, the other an ASR. The mean time to fracture was 3.4 months. The AVNs were retrieved after 16 months (Durom) and 38 months (ASR).

Volumetric wear rates were determined using a Mitutoyo Legex 322 co-ordinate measuring machine (scanning accuracy within 1 micron) and a bespoke computer program. The method was validated against gravimetric calculations for volumetric wear using a sample femoral head that was artificially worn in vitro. At 5mm³, 10mm³, and 15mm³ of material removal, the method was accurate to within 0.5mm³. Surface roughness data was collected using a Zygo NewView500 interferometer (resolution 1nm).

Mean wear rates of 17.74mm³/year were measured from the fracture components. Wear rates for the AVN retrievals were 0.43mm³/year and 3.45mm³/year. Mean roughness values of the fracture retrievals (PV = 0.754, RMS = 0.027) were similar to the AVNs (PV = 0.621, RMS = 0.030), though the AVNs had been in vivo for significantly longer.

Theoretical lubrication calculations were carried out which found that in both AVN retrievals and in seven of the twelve cases of femoral fracture the roughening was sufficient to change the lubrication regime from fluid film to mixed. Three of these surfaces were bordering on the boundary lubrication regime. The results show that even before the femoral fracture, wear rates and roughness values were high and the implants were performing poorly.

Hip resurfacing arthroplasty is emerging as an increasingly popular, conservative option for the treatment of end-stage osteoarthritis in the young and active patient. Despite the encouraging clinical results of hip resurfacing, aseptic loosening and femoral neck fracture remains concerns for the success of this procedure.

This study used finite element analysis (FEA) to analyse the stresses within proximal femoral bone resulting from implantation with a conservative hip prosthesis. FEA is a computational method used to analyse the performance of real-world structures through the development of simplified computational models using essential features.

The aim of this study was to examine the correlation between the orientation of the femoral component of a hip resurfacing prosthesis (using the Birmingham Hip Resurfacing as a model) and outcomes during both walking and stair climbing. The outcomes of interest were stresses in the femoral neck predisposing to fracture, and bone remodelling within the proximal femur.

Multiple three-dimensional finite element models of a resurfaced femur were generated, with stem-shaft angles representing anatomic (135°), valgus (145°), and varus (125°) angulations. Applied loading conditions included normal walking and stair climbing. Bone remodelling was assessed in both the medial and lateral cortices.

Analyses revealed that amongst all orientations, valgus positioning produced the most physiological stress patterns within these regions, thereby encouraging bone growth. Stress concentration was observed in cortical and cancellous bone regions adjacent to the rim of the prosthesis. As one would expect, stair climbing produced consistently higher stress than walking. The highest stress values occurred in the varus-orientated femur during both walking and stair climbing, whilst anatomic angulation resulted in the lowest stress values of all implanted femurs in comparison to the intact femur.

This study has shown through the use of FEA that optimising the stem-shaft angle towards a valgus orientation is recommended when implanting a hip resurfacing arthroplasty. This positioning produces physiological stress patterns within the proximal femur that are conducive to bone growth, thus reducing the risk of femoral neck fracture associated with conservative hip arthroplasty.

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Acetabulum fractures caused by civilian firearms represent a unique challenge for orthopaedic surgeons. Treatment strategies should include the assessment of infection risk due to frequently associated abdominal injuries and maintenance of joint function. Still, internationally accepted treatment algorithms are not available. The aim of the study was to increase knowledge about civilian gunshot fractures of the acetabulum by describing their characteristics and management at a high-volume tertiary hospital. All adult patients admitted to our hospital between January 2009 and December 2022 with civilian gunshot fractures of the acetabulum were included in this descriptive retrospective study. In total our institution treated 301 patients with civilian gunshot fractures of the hip joint and pelvis during the observation period, of which 54 involved the acetabulum. Most patients were young males (88,9%) with a mean age of 29 years. Thirty patients (55,6%) had associated intraabdominal or urological injuries. Fracture patterns were mostly stable fractures with minor joint destruction amenable to conservative fracture treatment (n=48, 88,9%). Orthopaedic surgical interventions were performed in 21 patients (38,9%) with removal of bullets in contact with the hip joint via arthrotomy or surgical hip dislocation as most frequent procedures. Most patients received antibiotics on admission (n=49, 90,7%). Fracture related infections of the acetabulum were noted in six patients (11,1%) while the mortality in the study population was low with one demised patient (1,9%) due to the trauma burden. Most civilian acetabulum gunshot fractures are associated with intraabdominal or urological injuries. In comparison to the literature on extremity gunshot fractures, there is an increased risk of infection in our study population. The decision for surgical wash-out and bullet removal should be based on contamination and anticipated joint destruction, while osteosynthesis or primary arthroplasty are rarely necessary for these injuries

Aim. Aim was to compare revision rates when using single versus dual antibiotic loaded cement (ABLC) in hip fracture arthroplasty and aseptic revision hip or knee arthroplasty using data from the Dutch national joint registry (LROI). Methods. All primary cemented (hemi-)arthroplasties for acute hip fractures and cemented aseptic hip or knee revision arthroplasties, were incorporated in 3 datasets. All registered implants between 2007 and 2018 were included (minimum 2 years follow-up). Primary end-point was subsequent revision rates for infection and for any reason in the single and dual ABLC groups. Cumulative crude incidence of revision was calculated using competing risk analysis. Results. A total of 22,308 hip fracture arthroplasties, 2,529 hip revision and 7,124 knee revision arthroplasties were registered and analyzed in the study period. The majority of hip fracture patients (97.1%) was treated with single ABLC. For hip and knee revision arthroplasties dual ABLC was used in 33.8% and 25.7%. The revision rate for infection in the fracture arthroplasty group was not different between groups (0.5% versus 0.8%, p=0.27). The re-revision rate following hip or knee revision based on single versus dual ABLC was not different between groups (3.2% versus 2.8%, p=0.82 for hip revision and 1.8% versus 2.5%, p=0.36 for knee revision). In addition, the re-revision rate for any reason was not different in all three datasets. The crude cumulative revision and re-revision rates for any reason based on single ABLC versus dual ABLC showed no differences in all three datasets. The crude cumulative 7-year re-revision rate for any reason following revision THA with Gentamicin ABLC use was 11.8%, with Gentamicin + Clindamycin ABLC use 13.1% and with Erythromycin + Colistin ABLC use 14.8% (ns). The crude cumulative 9-year re-revision rate for any reason following revision TKA with Gentamicin ABLC use was 17.7% and with Gentamicin + Clindamycin ABLC use 16.5% (ns). Conclusions. In conclusion, we could not show a difference in revision rate for hip fracture arthroplasty or re-revision rates for revision hip- or knee arthroplasty with the use of dual ABLC compared to single ABLC bone cement, with 7and 9 year follow up. The low percentage of dual ABLC in hip fracture arthroplasties in our registry do not enable us to make a reliable estimation of the added value in this patient category. The results of this study do not confirm the potential benefit of dual ABLC use in revision cases

Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the Duplex. TM. implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection

Background. In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless. Aim. To assess differences in patient reported outcomes in uncemented THAs based on patient demographics in order to decide when cementless THA can be done safely. Method. Prospective data collection of consecutive 1079 uncemented THAs performed for 954 patients in single trust between 2010 and 2020. Oxford Hip Score (OHS) and complications were analysed against demographic variables (age, sex, BMI, ASA) and prosthesis features (femoral and acetabular size, offset and acetabular screws). Results. The mean pre-operative OHS was 14.6 which improved to 39.0 at 1 year follow up (P Value=0.000). There was no statistically significant difference between OHS outcome in patients aged over 70 versus younger groups. With a small number of revisable complications increase with age from 50s upwards. Male patients’ OHS score was on average 2.4 points higher than women. Men, however were 2.9 times more likely to experience fractures and high offset hips were 2.5 times more likely to experience dislocations. DAIR, intraoperative calcar fractures, post-operative fractures and dislocations were not associated with worse OHS. Patients with increased BMI had worse pre and post-operative hip functions yet, there was a significant multivariate association between increased BMI and increased improvement in OHS from pre-op to 1 year in women aged 55–80 and men under the age of 60. Femoral stem size increases with age but decreases in male patients over 80. There was no difference found in OHS between bilateral hip replacements and unilateral, nor was there any change found with laterality side of the replacement. Conclusions. This study suggests that ageing >70 is not associated with poorer outcomes despite small number of revisable complication rates that increase with age from 50 upwards. Men had marginally higher average OHS than women At 1 year. Higher BMI or ASA scores are associated with worse pre-operative hips and worse final outcome score. Despite this, the Delta OHS increases with increased BMI shown in the 55–80 year old female patients and male patients under 60. Key Words: THR, Uncemented, Oxford hip score, outcome

Abstract. Background. Dislocation of a hip hemiarthroplasty is a devastating complication with a high mortality rate in elderly patients. Previous studies have suggested a higher dislocation rate in patients with neuromuscular conditions. In this study, we have reviewed our larger cohort of patients to identify whether there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for femoral neck fractures. Patients and Methods. Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population is composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with dementia. Results. A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe dementia with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p=0.02) while none of the other neuromuscular conditions were statistically significant. Conclusion. Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson's disease in comparison to other groups. No increase was apparent for those with dementia or weakness from a previous stroke

This study was designed to compare atypical hip fractures with a matched cohort of standard hip fractures to evaluate the difference in outcomes. Patients from the American College of Surgeons National Surgical Quality Improvement Program's (NSQIP) targeted hip fracture data file (containing a more comprehensive set of variables collected on 9,390 specially targeted hip fracture patients, including the differentiation of atypical from standard hip fractures) were merged with the standard 2016 NSQIP data file. Atypical hip fracture patients aged 18 years and older in 2016 were identified via the targeted hip fracture data file and matched to two standard hip fracture controls by age, sex, and fracture location. Patient demographics, length of hospital stay, 30-day mortality, major and minor complications, and other hip-specific variables were identified from the database. Binary outcomes were compared using the McNemar's test for paired groups, and continuous outcomes were compared using a paired t-test. Ninety-five atypical hip fractures were identified, and compared to 190 age, sex, and fracture location matched standard hip fracture controls. There was no statistical difference in body mass index (BMI), race, ASA score, smoking status, timing of fixation, or functional status between the two groups (P>0.05). Thirty-day mortality was significantly higher in the atypical hip fracture group (atypical 7.36%, standard 2.11% p. This is the first study, to our knowledge, that demonstrates an increase in the rate of mortality in atypical hip fractures. Comparing atypical hip fractures with a matched cohort of standard hip fractures revealed a significantly greater 30-day mortality rate with an odds ratio of 3.62 in atypical hip fractures (95% CI 1.03–12.68). Prospective, clinical studies are recommended to further investigate these findings

Pathologic fractures about the hip are an uncommon, but increasingly prevalent, clinical scenario encountered by orthopaedic surgeons. These fractures about the hip usually necessitate operative management. Life expectancy must be taken into account in management, but if survivorship is greater than 1 month, operative intervention is indicated. Determination must be made prior to operative management if the lesion is a solitary or metastatic lesion. Imaging of the entire femur is necessary to determine if there are other lesions present. Bone lesions that have a large size, permeative appearance, soft tissue mass, and rapid growth are all characteristics that suggest an aggressive lesion. Biopsy of the lesion in coordination with the operative surgeon should be conducted if the primary tumor is unknown. Metastatic disease is much more common than primary tumors in the adult population. Many metastatic fractures in the intertrochanteric region, and all fractures in the femoral neck and head are an indication for hemiarthroplasty or total hip arthroplasty. Cemented femoral implants are generally indicated. This allows immediate weight bearing in a bone with compromised bone stock, thus reducing the risk of peri-operative fractures. Additionally, patients are often treated with radiation and/or chemotherapy, which may prevent proper osseointegration of an ingrowth femoral component. Highly porous ingrowth shells have been shown to provide reliable and durable fixation even in these situations. Management of a periacetabular pathologic fracture, particularly resulting in a pelvic discontinuity is a particularly challenging situation. Use of a highly porous acetabular component combined with an acetabular cage, a custom acetabular component, a cemented Harrington technique, or a primary acetabular reconstruction cage may be utilised. Patients with neoplastic disease are often at risk for infection and thromboembolic disease both from the disease and treatment. Pre-operative evaluation of nutrition status by measuring albumin and pre-albumin will give the surgeon insight. Additionally, dehydration is commonly seen in cancer patients, and adequate pre-operative optimization of fluids and electrolytes may reduce peri-operative complications from other organ systems

Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA). We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91 years) were treated for a Vancouver type B1 fracture between 1998 and 2013. The status of the initial arthroplasty was THA in 5 patients and BHA in 6 patients. The original diagnosis was femoral neck fracture in 5 patients, osteoarthritis in 5 patients, and avascular necrosis of femoral head in 1 patient. Seven patients had had a cemented femoral component and 4 had had a cementless femoral component. The mean numbers of previous surgeries were 3.2 times (2 to 5 times). A previous history of fracture in the same femur was found in 7 hips including 5 femoral neck fractures, 3 periprosthetic fractures. The cause of the latest revision surgery was aseptic loosening in 6 hips, periprosthetic fracture in 3 hips, and infection in 2 hips. The average time to fracture after femoral revision using a long stem was 106.5 months (12 to 240 months). The average follow-up was 58.9 months (8 to 180 months). The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Seven patients were treated with a locking compression plate and cerclage wiring, and 2 patients were treated with a Dall-Miles system. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with very poor bone quality, which received a femoral revision with a long stem and a locking compression plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful. These finding suggest that a type B1 fracture after revision using a long stem associated with very poor bone quality or bone loss might be considered as a type B3 fracture, and femoral revision might be the treatment of choice

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Introduction. The incidence of periprosthetic fractures is increasing as the population ages. Wound complications and surgical site infections following surgery to treat periprosthetic fractures are a major source of patient morbidity and health care burden. This study evaluates the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after periprosthetic fracture surgery about the hip and knee. Methods. An IRB-approved retrospective quality improvement analysis of sixty-five consecutive periprosthetic fracture surgeries performed by four surgeons at a single institution in a fifteen-year period was performed. ciNPT was selectively used on patients in the last 20 months of the study period. Rates of wound complications, surgical site infections, and reoperation were compared with those of a sterile antimicrobial dressing (AMD). Results. AMD was used on 44 patients, while ciNPT was used in 21 patients. Compared with those treated with AMD, patients treated with ciPNT developed fewer wound complications 5% (1/21) vs 25% (11/44) (p = 0.045), deep infections 0% (0/21) vs 20% (9/44) (p = 0.014), and underwent fewer reoperations 5% (1/21) vs 20% (9/44) (p = 0.045). All patients had at least thirty days of follow up. Conclusion. Our findings suggest that ciNPT decreases the incidence of wound complications, deep infections, and reoperations in patients requiring surgical management of periprosthetic fractures about the hip and knee

Fragility fractures associated with osteoporosis (OP) reduce quality of life, increase risk for subsequent fractures, and are a major economic burden. In 2010, Osteoporosis Canada produced clinical practice guidelines on the management of OP patients at risk for fractures (Papaioannou et al. CMAJ 2010). We describe the real-world incidence of primary and subsequent fragility fractures in elderly Canadians in Ontario, Canada in a timespan (2011–2017) following guideline introduction. This retrospective observational study used de-identified health services administrative data generated from the publicly funded healthcare system in Ontario, Canada from the Institute for Clinical Evaluative Sciences. The study population included individuals ≥66 years of age who were hospitalized with a primary (i.e. index) fragility fracture (identified using ICD-10 codes from hospital admissions, emergency and ambulatory care) occurring between January 1, 2011 and March 31, 2015. All relevant anatomical sites for fragility fractures were examined, including (but not limited to): hip, vertebral, humerus, wrist, radius and ulna, pelvis, and femur. OP treatment in the year prior to fracture and subsequent fracture information were collected until March 31, 2017. Patients with previous fragility fractures over five years prior to the index fracture, and those fractures associated with trauma codes, were excluded. 115,776 patients with an index fracture were included in the analysis. Mean (standard deviation) age at index fracture was 80.4 (8.3) years. In the year prior to index fracture, 32,772 (28.3%) patients received OP treatment. The incidence of index fractures per 1,000 persons (95% confidence interval) from 2011–2015 ranged from 15.16 (14.98–15.35) to 16.32 (16.14–16.51). Of all examined index fracture types, hip fractures occurred in the greatest proportion (27.3%) of patients (Table). The proportion of patients incurring a second fracture of any type ranged from 13.4% (tibia, fibula, knee, or foot index fracture) to 23% (vertebral index fracture). Hip fractures were the most common subsequent fracture type and the proportion of subsequent hip fractures was highest in patients with an index hip fracture (Table). The median (interquartile range [IQR]) time to second fracture ranged from 436 (69–939) days (radius and ulna index fracture) to 640 (297–1,023) days (tibia, fibula, knee, or foot index fracture). The median (IQR) time from second to third fracture ranged from 237 (75–535) days (pelvis index fracture) to 384 (113–608) days (femur index fracture). This real-world study found that elderly patients in Ontario, Canada incurring a primary fragility fracture from 2011–2015 were at risk for future fractures occurring over shorter periods of time with each subsequent fracture. These observations are consistent with previous reports of imminent fracture risk and the fragility fracture cascade in OP patients (Balasubramanian et al. ASBMR 2016, Toth et al. WCO-IOF-ESCEO 2018). Overall, these data suggest that in elderly patients with an index fragility fracture at any site (with the exception of the radius or ulna), the most likely subsequent fracture will occur at the hip in less than 2 years

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

Aims. Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. Methods. This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. Results. The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. Conclusion. In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782–787

Introduction. Modern ceramic-on-ceramic bearings have become attractive alternatives to conventional polyethylene due to their low wear and minimal particle production. However, ceramic-on-ceramic implants have been associated with ceramic fracture and squeaking. To address these issues, large ceramic heads with a titanium-alloy sleeve have been introduced although limited data are available on their clinical outcomes. The purpose of this study was to report the midterm results of primary total hip arthroplasty using a 32mm with a titanium-alloy sleeve. Materials & Methods. We reviewed 245 patients who had 274 total hip arthroplasties with a 32 mm ceramic head with a titanium-alloy sleeve and had been followed for more than 5 years (average, 6.5 years; range, 5–9 years). The mean patient age at the time of surgery was 55.1 years (range, 16–82 years). All operations were performed at a single center. All of the ceramic implants were hot isostatic pressed, laser-marked, proof-tested third-generation alumina (Fig. 1). We determined the implant survival, Harris hip scores, incidence of ceramic fracture or noisy hips, and presence of osteolysis. Results. The survival rate of ceramic-on-ceramic bearings in primary total hip arthroplasty using 32 mm ceramic head with titanium-alloy sleeve was 97.5% at 9 years (Fig. 2). The Harris hip score improved from mean of 47 preoperatively to 93 at last follow-up. One ceramic head fractured at 6 years postoperatively. No ceramic liners were seen to fracture. Audible hip noise was identified in five hips (1.8%); clicking in four and squeaking in one. Osteolysis was detected in four hips (1.5%), but all had no symptom (Fig. 3). Other complications included three deep infections, two dislocations, and one peroneal nerve palsy. Conclusions. Primary ceramic-on-ceramic total hip arthroplasty using a 32 mm ceramic head with a titanium-alloy sleeve has a high survival rate of 97.5% at a 9-year follow-up. Nevertheless, surgeons should be aware of the potential risks of ceramic fracture, noise, and osteolysis associated with the use of ceramic head with a titanium-alloy sleeve

The most common classification of periprosthetic femoral fractures is the Vancouver classification. The classification has been validated by multiple centers. Fractures are distinguished by location, stability of the femoral component, and bone quality. Although postoperative and intraoperative fractures are classified using the same three regions, the treatment algorithm is slightly different. Type A fractures involve the greater and lesser trochanter. Fractures around the stem or just distal to the stem are Type B and subcategorised depending on stem stability and bone quality. Type C fractures are well distal to the stem and are treated independent of the stem with standard fixation techniques. The majority of fractures are either B1 (stable stem) or B2 (unstable stem). The stem is retained and ORIF of the fracture performed for B1 fractures. B2 and B3 fractures require stem revision with primary stem fixation distal to the fracture. Intraoperative fractures use the same A, B, C regions but are subtyped 1–3 as cortical perforations, nondisplaced, and displaced unstable fractures, respectively. With the exception of A1 intraoperative fractures all other intraoperative fractures require surgical treatment. A recent publication utilizing a New York state registry highlighted the patient risk of mortality associated with periprosthetic hip fractures. One month, 6 month and 1 year mortality was 3.2%, 3.8% and 9.7%, respectively. The mortality risk was lower for periprosthetic fractures treated with ORIF at 1 and 6 months compared to fractures requiring revision total hip

Subcapital fractures about the hip continue to be a common clinical scenario with which we all face. There are estimated to be over 350,000 hip fractures annually in the U.S. with 40% being displaced femoral neck fractures. The mean cost is over $30,000. Optimizing surgical care is essential with the overall goal being to perform the most effective treatment with the lowest risk of reoperation that provides the best postoperative function and pain relief. In the “young” (which is often defined as whatever age is younger than you!) reduction and internal fixation is often the most effective retaining the native femoral head. The risk of non-union and AVN is often less than potential complications that can follow an arthroplasty with 40% of displaced fractures treated with ORIF eventually requiring reoperation. Essentially for every 100 patients that undergo ORIF for displaced femoral neck fracture, choosing arthroplasty instead results in 17 conversions avoided. In the “elderly” in general we treat all displaced fractures with a total hip replacement which reduced re-admissions and is more cost effective for displaced femoral neck fractures. Aside from the medical morbidity following an arthroplasty dislocation is the primary concern. We have found the anterolateral approach reduces this significantly. Non-displaced fractures that are valgus impacted and biomechanically stable are treated with cannulated screws. Perhaps it can be argued that a hemiarthroplasty (bipolar or monopolar) has a lower risk of dislocation compared to a total hip replacement if performed by a surgical team with less frequent total hip replacement experience. However, total hip replacement results in less pain and better function when the patients are independent with intact mental status (patient not the surgeon…!). My algorithm is non-displaced valgus impacted or “stable” fractures undergo cannulated screws and the displaced fractures receive a total hip arthroplasty via an anterolateral approach