Introduction. Functional scores are used to clinically assess total hip arthroplasty (THA) and for comparative purposes in the orthopaedic literature. Previous research has highlighted patient age, gender and underlying diagnosis as potential sources of bias but comorbidity has not been considered. The Functional Comorbidity Index (FCI) is a published epidemiological tool which correlates disease with associated physical function deficit. It scores 18 conditions: one point for each, total score 0–18. Method & Results. We analysed 41 fully cemented primary THAs in patients ≤55 years at time of surgery with a minimum 10 years follow up. Past medical history was collected via thorough case note review. Patients were assessed using the SF-12 questionnaire, Harris Hip and WOMAC indexes. The study population consisted of 29 patients: 12 women, 17 men. Mean age: 45 years (range 22–53). All patients received cemented polished Corin TaperFit stem with polyethylene Ogee cup. Mean follow up 13.4 years (range 10.2–17.7). FCI scores ranged 0–3 (12 hips=0; 19 hips=1, 5 hips=2, 5 hips=4). A Pearson's product-moment correlation coefficient was calculated to assess the relationship between co-morbidity and hip function score using all three indexes. SF-12 score: Mean (M) =88.7; Standard Deviation (SD) =19.3; Range 0–166. Mean by FCI subgroup: 0=91, 1=96, 2=76.8, 3=68.6 (r=−0.407). HHS: M=83.8; SD=17.0; Range 45–100. Mean by FCI subgroup: 0=94.7; 1=88.2, 2=63.5, 3=54.6 (r= −0.813). WOMAC: M=79.1; SD=20.7; Range 34–100. Mean by FCI subgroup: 0=94.4, 1=91.72, 2=48.8, 3=37.4 (r=−0.812). Discussion & Conclusion. Satisfaction was extremely high with 98% of patients “extremely likely” to recommend this treatment to friends or family. Increasing FCI score correlated with decreasing hip function scores in all three indexes. This study suggests a strong negative correlation between patient comorbidity and hip function scores in THA patients. When comparing functional scores, particularly across patient and implant groups, adjustment for patient comorbidities should be made to ensure balanced evaluation

Functional scores are used to clinically assess total hip arthroplasty (THA) and for comparative purposes in orthopaedic literature. Previous pilot work has highlighted patient comorbidity as a potential source of bias in addition to the often-examined factors of age, gender and underlying diagnosis. We analysed prospectively collected data relating to 217 primary THAs (Tayside Arthroplasty Audit Group database). Sample size was calculated from previous pilot data (significance level 5%, power 80%, effect size 0.25). Proportional stratified sampling was performed including all patient age groups (≤40, 41–55, 56–65, >65) and four fixation classes (cemented, hybrid, uncemented and Birmingham resurfacing). Five year Harris Hip Function Score (HHFS) was the dependent variable; age, sex, underlying diagnosis, BMI, pre-operative HHFS and comorbidity (Functional Comorbidity Index; range 0–8) were co-variates/co-factors. In univariate analysis, FCI accounted for 11% of the variation in HHFS at 5 years. Regarding patients with FCI 0–1 as a reference group, patients with greater comorbidity had lower HHFS at 5 years (FCI 2–3: −3.95; FCI 4–5: −7.21, FCI ≥6: −6.92). In a multivariable model of HHFS at 5 years, FCI group, diagnosis, pre-operative HHFS, patient age and BMI were significant. HHFS at 5 years was significantly higher in FCI group 0–1 than any other category (2–3 P=0.006, 4–5 P<0.001, ≥6 P=0.002). In total, the model accounted for 29% of variability in HHFS at 5 years. This is the first statistically robust study to examine the effect of comorbidity on THA function. These results strongly suggest that increasing patient comorbidity is associated with poorer THA function when measured using HHS. Two significant conclusions can be drawn:. Patient comorbidity should be taken into account pre-operatively when considering potential future THA function. When comparing across implants, failure to give specific consideration to comorbidity of patient groups will limit relevance and weight of findings

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

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

Aims

To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Aims

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component.

Aims. While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. Methods. In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. Results. A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). Conclusion. The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3–8

Aims. Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA). Methods. We analyzed 151,096 primary cementless THAs from the German Arthroplasty Registry (EPRD) between November 2012 and November 2020. Cumulative incidence of revision for mechanical complications for standard and four modified PE liners (lipped, offset, angulated/offset, and angulated) was determined using competing risk analysis at one and seven years. Confounders were investigated with a Cox proportional-hazards model. Results. Median follow-up was 868 days (interquartile range 418 to 1,364). The offset liner design reduced the risk of revision (hazard ratio (HR) 0.68 (95% confidence interval (CI) 0.50 to 0.92)), while the angulated/offset liner increased the risk of revision for mechanical failure (HR 1.81 (95% CI 1.38 to 2.36)). The cumulative incidence of revision was lowest for the offset liner at one and seven years (1.0% (95% CI 0.7 to 1.3) and 1.8% (95% CI 1.0 to 3.0)). No difference was found between standard, lipped, and angulated liner designs. Higher age at index primary THA and an Elixhauser Comorbidity Index greater than 0 increased the revision risk in the first year after surgery. Implantation of a higher proportion of a single design of liner in a hospital reduced revision risk slightly but significantly (p = 0.001). Conclusion. The use of standard acetabular component liners remains a good choice in primary uncemented THA, as most modified liner designs were not associated with a reduced risk of revision for mechanical failure. Offset liner designs were found to be beneficial and angulated/offset liner designs were associated with higher risks of revision. Cite this article: Bone Joint J 2022;104-B(7):801–810

Aims. The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality. Methods. Patients undergoing one- or two-stage revision of a primary THA for PJI between January 2008 and January 2021 were identified. Age, sex, BMI, American Society of Anesthesiologists grade, Charlson Comorbidity Index (CCI), McPherson systemic host grade, and causative organism were collated for all patients. PJI was classified as ‘confirmed’, ‘likely’, or ‘unlikely’ according to the 2021 European Bone and Joint Infection Society criteria. Primary outcomes were complications, reoperation, re-revision, and successful treatment of PJI. A total of 37 patients aged 80 years or older and 120 patients aged under 80 years were identified. The octogenarian group had a significantly lower BMI and significantly higher CCI and McPherson systemic host grades compared to the younger cohort. Results. The majority of patients were planned to undergo two-stage revision, although a significantly higher proportion of the octogenarians did not proceed with the second stage (38.7% (n = 12) vs 14.8% (n = 16); p = 0.003). Although there was some evidence of a lower complication rate in the younger cohort, this did not reach statistical significance (p = 0.065). No significant difference in reoperation (21.6% (n = 8) vs 25.0% (n = 30); p = 0.675) or re-revision rate (8.1% (n = 3) vs 16.7% (n = 20); p = 0.288) was identified between the groups. There was no difference in treatment success between groups (octogenarian 89.2% (n = 33) vs control 82.5% (n = 99); p = 0.444). Conclusion. When compared to a younger cohort, octogenarians did not show a significant difference in complication, re-revision, or treatment success rates. However, given they are less likely to be eligible to proceed with second stage revision, consideration should be given to either single-stage revision or use of an articulated spacer to maximize functional outcomes. Cite this article: Bone Joint J 2024;106-B(8):802–807

Aims. It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively. Methods. Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis. Results. The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon’s age) was not a significant factor. Conclusion. Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826–832

Aims. Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution. Methods. We identified 33 patients who underwent treatment for PJIs of the hip between January 2010 and December 2019 using our institutional joint registry. Mean age was 82 years (80 to 90), with 19 females (57%) and a mean BMI of 26 kg/m. 2. (17 to 41). Mean American Society of Anesthesiologists (ASA) grade was 3 (1 to 4) and mean Charlson Comorbidity Index was 6 (4 to 10). Leading pathogens included coagulase-negative Staphylococci (45%) and Enterococcus faecalis (9%). Two-stage exchange was performed in 30 joints and permanent resection arthroplasty in three. Kaplan-Meier survivorship analyses were performed. Mean follow-up was five years (3 to 7). Results. The two-year survivorship free of any recurrent PJI was 72% (95% confidence interval (CI) 56 to 89; 18 patients at risk). There were a total of nine recurrent PJIs at a mean of one year (16 days to eight years), one for the same pathogen as at index infection. One additional surgical site infection was noted at two weeks, resulting in a 69% (95% CI 52 to 86; 17 patients at risk) survivorship free of any infection at two years. There were two additional revisions for dislocations at one month each. As such, the two-year survivorship free of any revision was 61% (95% CI 42 to 80; 12 patients at risk). In addition to the aforementioned revisions, there was one additional skin grafting for a decubitus ulcer, resulting in a survivorship free of any reoperation of 54% (95% CI 35 to 73; ten patients at risk) at two years. Mean Clavien-Dindo score of perioperative complications was two out of five, with one case of perioperative death noted at six days. Conclusion. Octogenarians undergoing surgery for PJI of the hip are at low risk of acute mortality, but are at moderate risk of other perioperative complications. One in two patients will undergo a reoperation within two years, with 70% attributable to recurrent infections. Cite this article: Bone Joint J 2023;105-B(2):135–139

Two-stage exchange revision total hip arthroplasty performed in case of infection has been considered during many years the gold standard for treatment of chronic infection. Nevertheless, during the last decade, concerns have risen regarding its safety and its efficiency. The purpose of our study was to, first investigate the spacer complications, then to analyze their risks factors. We retrospectively included 125 patients with chronic hip periprosthetic joint infection who underwent a two stage exchange revision arthroplasty performed between January 2013 and December 2019. All spacer complications were systematically collected and risk factors were analyzed. Statistical evaluation were performed using the Student and Mann-Whitney tests. Our study confirms the hypothesis of a high-risk strategy with 42% of patients who had a mechanical spacer failure and a 20% recurrence of infection during the average two years period of follow-up. We found a high rate of spacer migration (23%) and a low rate of spacer fracture (8%) compared to literature. The most important finding was that the majority of spacer complications and failures were found in a population with high medical comorbidities as highlighted by the ASA, Charlson and Lee score associations, as well as with the cardiac, pulmonary, kidney or hepatic chronic conditions. This study showed that a two-stage hip exchange revision is a high-risk procedure regarding complications and mechanical failures of PMMA spacers. In patients with high medical comorbidities, other strategies may be considered and interdisciplinary cooperation with other facilities are needed to identify and control each risk factor

Surgical treatment of Hip PJI by resection of the infected implants and tissue and placement of a “spacer” which elutes antibiotic via antibiotic loaded cement is an accepted treatment option. There is some controversy over whether this “spacer” should be articulating or static. Proponents of the articulating option argue that there is improved function and maintenance of the soft tissue envelop. Critics have suggested that additional biomaterials may compromise eradication of infection. This study compares our results of the 2 treatment options. A review of our institutional PJI database between 2016 and 2021 identified 87 patients who were treated with resection arthroplasty for unilateral total hip PJI. The cohort was analyzed for demographics and type for surgery, as well as medical comorbidities, survivorship, and treatment success. 44 patients were female, the mean age of all patients was 62. 44 patients were treated with Articulating apacers, and 43 patients treated with static spacers. There was no significant difference between ASA or Elixhauser score, and no significant difference between mortality or treatment failure. This study did not show any difference between the patients who receive static spacers, from those who received articulating spacers, and deomstrated similar treatment success rates. From this data there does not appear to be any difference in success rates between those patients that were treated with static spacers and those that were treated with articulating spacers

Periprosthetic joint infections (PJIs) centers are garnering the attention of different arthroplasty surgeons and practices alike. Nonetheless, their value has yet to be proven. Therefore, we evaluated weather PJI centers produce comparable outcomes to the national average of THA PJIs on a national cohort. We performed a retrospective review of patient data available on PearlDiver from 2015 – 2021. PJI THA cases were identified through ICD-10 and CPT codes. Patients treated by 6 fellowship trained arthroplasty surgeons from a PJI center were matched based on age, gender, Charlson Comorbidity Index and Elixhauser comorbidity index at a 1:1 ratio to patients from the national cohort. Compared outcomes included LOS, ED visits, number of patients readmitted, total readmissions. Sample sized did not allow the evaluation of amputation, fusion or explantation. Normality was tested through the Kolmogorov-Smirnov test. And comparisons were made with Students t-tests and Chi Square testing. A total of 33,001 THA PJIs and were identified. A total of 77 patients were identified as treated by the PJI center cohort and successfully matched. No differences were noted in regard to age, gender distribution, CCI or ECI (p=1, 1, 1 and 0.9958 respectively). Significant differences were noted in mean LOS (p<0.43), number of patients requiring readmissions (p=0.001) and total number of readmission events (p<0.001). No difference was noted on ED visits. Our study demonstrates that a PJI for THA cases may be beneficial for the national growing trend of arthroplasty volume. Future data, that allows comparison of patient's specific data will allow for further validation of PJI centers and how these can play a role in helping the national PJI growing problem

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Patients with a high comorbidity burden (high-risk) can achieve similar improvements in quality of life compared to low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences THA outcomes in high-risk patients has not been investigated. This study aimed to compare complication rates and implant survivorship in high-risk patients operated on by high volume (HV) and non-HV THA surgeons. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologist Classification of 3 or 4 undergoing primary, elective THA between 2013 and 2021 were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Ninety day readmissions and revisions were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Years of experience were comparable between Non-HV and HV surgeons (p=0.733). The HV group had significantly shorter surgical times (p<0.001), and shorter length of stay (p=0.009) compared to the Non-HV group. The HV group also had significantly fewer 90-day readmissions (p=0.030), all-cause revisions (p=0.023) and septic revisions (p=0.020) compared to the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p=0.023) and septic revision (p=0.020) compared to the non-HV group. High-risk THA patients have fewer 90-day readmissions, all-cause revisions, septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a high comorbidity burden may benefit from referral to high-volume surgeons to reduce procedural risk and improve postoperative outcomes

Total hip arthroplasty (THA) is often performed in symptomatic patients with developmental dysplasia of the hip (DDH) who do not qualify for periacetabular osteotomy (PAO). The impact of osteoarthritis (OA) severity on postoperative outcomes in DDH patients who undergo THA is not well described. We hypothesized that DDH patients who undergo THA with mild OA have slower initial recovery postoperatively, but similar one-year patient reported outcome measures (PROMs) when compared to DDH patients with severe OA. We performed a retrospective review at a single academic institution over a six-year period of patients with DDH who underwent primary THA and compared them to patients without DDH who underwent THA. Within the DDH cohort, we compared PROMs stratified by DDH severity and OA severity. Diagnosis of DDH was verified using radiographic lateral center edge angle (LCEA). Minimum one-year follow-up was required. PROMs were collected through one-year postoperatively. Logistic and linear regression models were used adjusting for age, sex, body mass index, and Charlson Comorbidity Index. 263 patients with DDH were compared to 1,225 THA patients without DDH. No significant differences were found in postoperative PROMs or revision rates (p=0.49). When stratified by DDH severity, patients with LCEA<10° had worse preoperative pain (p=0.01), mental health (p<0.01) and physical function (p=0.03) scores but no significant difference in postoperative PROMs. Within the DDH group, when stratified by OA severity, patients with Grade 3 Tonnis score had worse preoperative pain (p=0.04) but no significant difference in postoperative PROMs. Recovery curves in DDH patients based upon severity of DDH and OA were not significantly different at 2-weeks, 6-weeks and 1-year. DDH patients who have mild OA have similar recovery curves compared to those with severe OA. THA is reasonable in symptomatic DDH patients who have mild arthritis and do not qualify for PAO

Aims. This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions. 132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05. There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication. Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time

Aims. Although there is increasing legalization of the use of cannabis in the USA, few well-powered studies have evaluated the association between cannabis use disorder and outcomes following primary total hip arthroplasty (THA). Thus, the aim of this study was to determine whether patients who use cannabis and undergo primary THA have higher rates of in-hospital length of stay (LOS), medical complications, implant-related complications, and costs. Methods. Using an administrative database, patients with cannabis use disorder undergoing primary THA were matched to a control group in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 23,030 patients (3,842 in the study group matched with 19,188 in the control group). The variables which were studied included LOS, 90-day medical complications, two-year implant-related complications, and 90-day costs of care. Mann-Whitney U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. Results. We found that patients in the study group had a significantly longer mean LOS compared with the controls (four days vs three days; p < 0.0001).The study group also had a significantly higher incidence and odds of developing medical (23.0 vs 9.8%, OR 1.6; p < 0.0001) and implant-related complications (16 vs 7.4%, OR 1.6; p < 0.0001) and incurred significantly higher mean 90-day costs ($16,938.00 vs $16,023.00; p < 0.0001). Conclusion. With the increasing rates of cannabis use, these findings allow orthopaedic surgeons and other healthcare professionals to counsel patients with cannabis use disorder about the possible outcomes following their THA, with increased hospital stays, complications, and costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):111–115