Aims. Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. Methods. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. Results. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Conclusion. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity. Cite this article: Bone Jt Open 2022;3(10):741–745

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

Aims

The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

This study assesses the incidence of noise in ceramic on ceramic (COC) bearings compared to metal on polyethylene (MOP) bearings. Noise after MOP implants has rarely been studied and they never been linked to squeaking. We have developed a noise characterising hip questionnaire and sent it along with the Oxford Hip Score (OHS) to 1000 patients; 509 respondents, 282 COC and 227 MOP; median age 63.7 (range 45–92), median follow up 2.9 years (range 6–156 months). 47 (17%) of the COC patients reported noise compared to 19 (8%) of the MOP patients (P=0.048). 9 COC and 4 MOP patients reported their hip noise as squeaking. We found the incidence of squeaking in the COC hips to be 3.2% compared to 1.8% in the MOP hips. Overall, 27% patients with noise reported avoiding recreational activities because of it and patient's with noisy hips scored on average 4 points less in the OHS (COC: P=0.04 and MOP: P =0.007). This is the first study to report squeaking from MOP hip replacements. We therefore believe the squeaking hip phenomenon is not exclusive to hard bearings. Surprisingly, only a small proportion of patients described nose from their as a ‘squeak’. Noisy hip implants may have social implications, and patients should be aware of this. We have shown a relationship between noise and a lower OHS. However, longer follow-up and further study is needed to link noise to a poorly functioning implant

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control. This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery. Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability

Background. Wear particles are considered to be the major culprit for the aseptic loosening. Their characterization is thus crucial for the understanding of their bioreactivity and contribution to the development of aseptic loosening. Methods. Metal wear debris particles were analyzed directly in periprosthetic tissue resins by scanning electron microscopy (SEM) combined with back-scattered electron imaging (BSE) and energy dispersive X-ray spectroscopy (EDS). Four groups of tissue samples retrieved at revision operations of loosened hip implants with different bearing surfaces (metal-on-metal, ceramic-on-polyethylene and metal-on-polyethylene), and different material of the femoral stem (Ti alloy, CoCrMo and polymer combined with stainless steel) were investigated. Tissue samples were first analyzed histologicaly. Sections from the same paraffin blocks were then carbon coated and analyzed using SEM/BSE/EDS method. Results. Metal particles were detected in all samples. Their composition corresponded to the composition of the implant components. The gradation of metal particles ranged from +1 to +3. A considerable number of big metal particles were actually agglomerates of submicron particles visible only at higher magnification. The clustering of particles was observed primarily for CoCrMo and, to a lesser extent, for stainless steels particles. The median sizes of CoCrMo clusters in two groups of samples were 2.9 1.8 m (range, 0.5 to 7.6 m) and 3.2 1.0 m (range, 1.9 to 5.4 m). The effect of clustering was not observed for Ti particles. The median sizes of individual Ti particles determined in two groups of samples were 2.5 3.6 m (range, 0.4 to 17.3 m) and 4.3 2.8 m (range, 0.8 to 11.0 m). Conclusion. Scanning electron microscopy combined with back-scattered electron imaging is an appropriate and selective method to recognize metal particles in tissue sections, without being destructive to specimens. When the size of the particles is considered, however, it should be differed between the size of individual particles and size of clusters of particles. Besides its benefits, this study has some limitations: the detection of particles smaller than 0.4 m is difficult, and this method cannot be used to identify polyethylene particles

INTRODUCTION. The advantages of large diameter metal on metal total hip arthroplasty (MoM THA) and hip resurfacing arthroplasty are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri-prosthetic osteolysis generated as a result of a biological response to particulate wear debris. No reports in the literature exist as to whether circulating levels of Chromium (Cr) and Cobalt (Co) decrease upon removal of a symptomatic large diameter MoM implant or whether levels remain high due to the effect of metal ions debris left behind in the soft tissues after revision surgery. PATIENTS AND METHODS. Between June 2006 and June 2009 we undertook 44 revision surgeries of both large head MoM THAs (femoral head diameter 38mm) and metal-on-metal hip resurfacings for suspected metallosis. Mean time from original implant to revision was 4 years, 8 months (1yr 4mo–7yr 9mo). The mean follow up evaluation was 2 years and 2 months (1yr 2mo–4 years). Blood samples were taken for whole blood Cr and serum Co according to a recognised protocol and compared with reference levels indicated by the Medicines and Healthcare Regulatory Agency recommendation of less than 7ppb for Cr (130nM/L) and Co (119nM/L). RESULTS. 42 patients were found to have histological evidence of either metal allergy, metal toxicity or foreign body reaction. 2 patients had evidence of infection with no features of metal reaction. 3 patients suffered early dislocation requiring closed reduction. 1 patient had infective complications necessitating Girdlestones. 11 patients were lost to follow up, 8 patients were diagnosed pre operatively on Co and Cr levels in urine or synovial fluid aspirate alone. 23 patients had pre revision blood or serum metal ion level results available for direct comparison. Median serum Co level pre revision was 176.6nM/L, falling post revision to 5.1nM/L (p=<0.001∗). The median whole blood Cr level pre revision was 117nM/L and 19nm/L post revision (p=<0.001∗). Mean Oxford Hip Score was 23.7. DISCUSSION. This study demonstrates that at greater than one year post removal of a large diameter MoM hip implant for the indication of symptomatic metallosis or metal hypersensitivity, metal ion levels fall to almost normal levels and that outcome of revision surgery in terms of patient satisfaction is not adversely affected

INTRODUCTION. Whilst there is a great deal of research on hip implants, few studies have looked at implant orientation and the subsequent effect upon the wear performance of a hip resurfacing. This study aimed to measure implantation angles through radiographic analysis and linear wear for retrieved acetabular cups in order to investigate possible causal links between wear and implant orientation. MATERIALS & METHODS. Seventy Birmingham Hip Resurfacing (Smith & Nephew, UK) cups with known time in vivo were analysed. Linear wear of retrieved cups were assessed using a Talyrond 290 roundness machine. Deviations from the characteristic manufactured profile, was identified as a region of wear. Polar measurements across the wear region were taken to determine wear. The linear wear rate (LWR) of a component was defined as the linear wear (μm) divided by the duration of the implant life in vivo (years). Cups which showed the wear crossing over the edge of the cup were classified as edge loaded (EL). For all non-edge loaded (NEL) cups, the wear area was within the bearing surface. Cup orientation angles were conducted for 31 cups. This was determined by superimposing BHR models of appropriate size, generated by CAD ProEngineer Wildfire 4, onto anterior-posterior x-rays. Anatomical landmarks and specific features of the BHR were used as points of reference to determine cup version and inclination angles. RESULTS. Forty two cups were classed as EL, showing regions of wear extending beyond the edge of the cup. Twenty eight were classed as NEL. The EL group had an average LWR of 25.4(±8.05 95% CL) μm/yr, whilst the NEL group generated an average LWR of 1.45 (±0.34 95% CL) μm/yr, a statistically significant difference (p<0.05).a Following radiographic analysis, 23 cups were classed as EL, showing regions of wear extending beyond the edge of the cup. Eight were classed as NEL. Cups in the EL group showed average inclination and version angles of 54.35° (±5.37° 95% CL) and 22.43° (±5.23° 95% CL). Average inclination and version angles of cups in the NEL group were 45° (±7.20° 95% CL), and 14.88° (±3.38° 95% CL) respectively. Inclination and version angles between the two groups were statistically significant (p<0.05). DISCUSSION. Through linear wear and radiographic analysis, the current study has shown that mal-positioned resurfacing devices classed as EL had higher linear wear than the NEL cups. Edge loaded cups examined in this study showed significantly higher inclination and anteversion (p<0.05) than the non-edge loaded devices. This indicates that component wear is closely associated with in vivo orientation. The success of any implant is dependent upon implant orientation both in version and inclination angles. The correct implant orientation will help to ensure that wear occurs within the bearing surfaces, maintaining an optimal lubrication regime and low wear

Although the importance of lateral femoral wall integrity is increasingly being recognised in the treatment of intertrochanteric fracture, little attention has been put on the development of a secondary post-operative fracture of the lateral wall. Patients with post-operative fractures of the lateral wall were reported to have high rates of re-operation and complication. To date, no predictors of post-operative lateral wall fracture have been reported. In this study, we investigated the reliability of lateral wall thickness as a predictor of lateral wall fracture after dynamic hip screw (DHS) implantation. A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures who received internal fixation with a DHS between January 2003 and May 2012 were reviewed. There were 103 men and 150 women with a mean age at operation of 78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected in 97 patients and the left side in 111. Clinical information including age, gender, side, fracture classification, tip–apex distance, follow-up time, lateral wall thickness and outcome were recorded and used in the statistical analysis. Fracture classification and lateral wall thickness significantly contributed to post-operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm. To our knowledge, this is the first study to investigate the risk factors of post-operative lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone. Cite this article: Bone Joint J 2013;95-B:1134–8

Introduction. The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon. Material and Methods. The frequency and the severity of the impingement were calculated from a continuous series of 311 cups retrievals collected between 1989 and 2004 by a single surgeon. The reason for retrieval was loosening (131 cases), infection (43 cases), instability (56 cases), osteolysis (28 cases), unexplained pain (48 cases) and prosthetic impingent (5 cases all with hard bearings). The notching at the cup rim was assessed twice by two examiners with optic magnification. The risk factors were analyzed from clinical charts by univariate and cox multihazard. Results. Among the 311 cups explants, the frequency of impingement was 59.2% (it was severe in 11%, the notching exceeding 3 millimeters). The impingement was the reason for removal in only 1.6%, meaning that it was mainly unexpected (98.4 percent). The impingement was more frequent when revisions were performed because of instability (notching 80%), when the sum of hip motion exceeded 200 degrees (sum of motion in the 6 degrees of freedom of the hip) (notching 66%). The other risk factors were: use of heads with skirts, liner with an elevated rim, and head-neck ratio below 2, younger age at surgery. The multivariate analysis identified only two independent factors: 1) the use of skirted heads (Odd ratio 3.2 (1.2–15.3)), 2) and revision because of instability (Odd ratio 4.2 (1.1–16.2)). In contrast different classical factors were not correlated with impingement on retrieval: cup inclination, the duration before retrieval, the indication for primary prosthetic replacement. Discussion and Conclusion. This study underlines the impingement is common when assessing cup retrievals (over 50 percent). One should be aware of impingement when performing hip replacement in patients having a high range of motion. This situation may require prostheses with a high head-neck ratio, as well as use of computer-assisted surgery. One should avoid liners with elevated rim as well as heads with skirts to prevent dislocation, particularly when other risk factors are detected

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.