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

Objectives. There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments. Methods. A long-term follow-up beyond the age of hip-joint maturity was performed for 115 hips in 103 patients who underwent open reduction using Ludloff’s medial approach in our hospital. The mean age at surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3 years (15 to 28). The radiological condition at full growth of the hip joint was evaluated by Severin’s classification. Results. All 115 hips successfully attained reduction after surgery; however, 74 hips (64.3%) required corrective surgery at a mean age of 2.6 years (one to six). According to Severin’s classification, 69 hips (60.0%) were classified as group I or II, which were considered to represent acceptable results. A total of 39 hips (33.9%) were group III and the remaining seven hips (6.1%) group IV. As to re-operation, 20 of 21 patients who underwent surgical reduction after 12 months of age required additional corrective surgeries during the growth period as the hip joint tended to subluxate gradually. Conclusion. Open reduction using Ludloff’s medial approach accomplished successful joint reduction for persistent CDH or DDH, but this surgical treatment was only appropriate before the ambulating stage. Cite this article: Bone Joint Res 2014;3:1–6

Aims. Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications. Methods. Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected. Results. Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported. Conclusion. Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction. Cite this article: Bone Jt Open 2024;5(1):28–36

Aims. The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. Methods. We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. Results. A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Conclusion. Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries. Cite this article: Bone Joint J 2024;106-B(2):144–150

Aims. The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). Methods. Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. Results. A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). Conclusion. Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable. Cite this article: Bone Joint J 2023;105-B(2):124–134

Aims. The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures. Methods. A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype. Results. The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype. Conclusion. Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible. Cite this article: Bone Jt Open 2023;4(1):38–46

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

Aims. The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes. Methods. A total of 76 patients treated for an IPFF from February 1985 to April 2018 were reviewed. Prior to fracture, at the hip/knee sites respectively, 46 femora had primary/primary, 21 had revision/primary, three had primary/revision, and six had revision/revision components. Mean age and BMI were 74 years (33 to 99) and 30 kg/m. 2. (21 to 46), respectively. Mean follow-up after fracture treatment was seven years (2 to 24). Results. Overall, 59 fractures were classified as Vancouver C (Unified Classification System (UCS) D), 17 were Vancouver B (UCS B). In total, 57 patients (75%) were treated with open reduction and internal fixation (ORIF); three developed nonunion, three developed periprosthetic joint infection, and two developed aseptic loosening. In all, 18 patients (24%) underwent revision arthroplasty including 13 revision THAs, four distal femoral arthroplasties (DFAs), and one revision TKA: of these, one patient developed aseptic loosening and two developed nonunion. Survivorship free from any reoperation was 82% (95% confidence interval (CI) 66.9% to 90.6%) and 77% (95% CI 49.4% to 90.7%) in the ORIF and revision groups at two years, respectively. ORIF patients who went on to union tended to have stemmed knee components and greater mean interprosthetic distance (IPD = 189 mm (SD 73.6) vs 163 mm (SD 36.7); p = 0.546) than nonunited fractures. Patients who went on to nonunion in the revision arthroplasty group had higher medullary diameter: cortical width ratio (2.5 (SD 1.7) vs 1.3 (SD 0.3); p = 0.008) and lower IPD (36 mm (SD 30.6) vs 214 mm (SD 32.1); p < 0.001). At latest follow-up, 95% of patients (n = 72) were ambulatory. Conclusion. Interprosthetic femur fractures are technically and biologically challenging cases. Individualized approaches to internal fixation versus revision arthroplasty led to an 81% (95% CI 68.3% to 88.6%) survivorship free from reoperation at two years with 95% of patients ambulatory. Continued improvements in management are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):122–128

Aims. The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods. This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results. Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. Conclusion. When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309–320

Constrained acetabular inserts provide a solution for both complex primary and revision hip arthroplasty, but there have been ongoing concerns for high risk of failure and their longevity. The Stryker® Trident acetabular insert is pre-assembled with its constrained ring. We believe this to be the largest series of constrained acetabular inserts with a minimum of 5 year follow-up. We retrospectively reviewed all Stryker® Trident ‘All-Poly’ constrained acetabular inserts cemented into bone in our unit between 2008 and 2016. We collated demographic details and reviewed all patients’ radiographs and clinical notes. Indications for surgery, latest Oxford Hip Scores (OHS) and clinical and radiographic complications were identified. 117 consecutive Stryker® Trident ‘All-Poly’ constrained inserts were cemented into bone in 115 patients during the study period with a mean age of 80 (47–97). Most common indications for surgery were recurrent dislocation (47), complex primary arthroplasty (23), revision arthroplasty (19) and failed hemiarthroplasty (12). 41 patients required revision of the acetabular component only. Follow-up was a minimum of 5 years (mean 8.6, range 5–13). There were three 30-day mortalities and six 1-year mortalities. The mean latest OHS was 37 (24–45). Four cups failed in three patients, one at the cement-bone interface, two at the cement-prosthesis interface and one at the bipolar interface. These were treated conservatively in three patient and with excision arthroplasty in one patient. There were four peri-prosthetic fractures, one Vancouver C distal femur fracture treated conservatively and three Vancouver B1 fractures, two treated conservatively and one treated with open reduction internal fixation. There was breakage of one constrained ring with no adverse effects and one superficial wound infection requiring oral antibiotics only. This series demonstrated that despite the elderly and complex nature of these patients’ clinical situations, constrained acetabular inserts offer a useful and pragmatic solution, with relatively low complications, including in our series a cup failure rate of 3% and peri-prosthetic fracture rate of 3%

Aims. When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity. Methods. From 1996 to 2005, 49 children (52 hips) were treated for late-detected DDH. Their mean age was 13.3 months (3 to 33) at reduction. Prereduction skin traction was used for a mean of 11 days (0 to 27). Gentle closed reduction under general anaesthesia was attempted in all the hips. Concurrent pelvic osteotomy was not performed. The hips were evaluated at one, three and five years after reduction, at age eight to ten years, and at skeletal maturity. Mean age at the last follow-up was 15.7 years (13 to 21). Results. Stable closed reduction was obtained in 36 hips (69%). Open reduction was more often necessary in patients ≥ 18 months of age at reduction (50%) compared with those under 18 months (24%). Residual hip dysplasia/subluxation occurred in 12 hips and was significantly associated with avascular necrosis (AVN) and with high acetabular index and low femoral head coverage the first years after reduction. Further surgery, mostly pelvic and femoral osteotomies to correct subluxation, was performed in eight hips (15%). The radiological outcome at skeletal maturity was satisfactory (Severin grades 1 or 2) in 43 hips (83%). Conclusions. Gentle closed reduction can be attempted in children up to three years of age, but is likely to be less successful in children aged over 18 months. There is a marked trend to spontaneous improvement of the acetabulum after reduction, even in patients aged over 18 months and therefore simultaneous pelvic osteotomy is not always necessary

The aim of this study is to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). This is a retrospective cohort study of 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems. 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Radiographs were assessed and classified by 3 observers. The primary outcome measure was revision of ≥1 component. Kaplan Meier survival analysis was performed. Logistic regression was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay and mortality. Fractures (B1 n=74 (49%); B2 n=50 (33%); and B3 n=28 (18%)) occurred at mean 6.7±10.4 years after primary THA (n=143) or hemiarthroplasty (n=15). Mean follow up was 6.5 ±2.6 years (3.2 to 12.1). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p=0.001) fractures and B3 fractures (p=0.05). Five-year survival was significantly better following ORIF: 92% (86.4 to 97.4 95%CI) Vs 63% (41.7 to 83.3), p<0.001. No independent predictors of revision following ORIF were identified: fixation of B2 or B3 fractures was not associated with an increased risk of revision. Dislocation was the commonest mode of failure after revision arthroplasty. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay or mortality between surgical groups. When the bone-cement interface was intact and the fracture was anatomically reducible, Vancouver B2 fractures around Exeter stems can be treated with fixation as opposed to revision arthroplasty. Fixation of Vancouver B3 fractures can be performed in frail elderly patients without increasing revision risk

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The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA).

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To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality.

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Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

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Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty.

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Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

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Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis.

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United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

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Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.