Aims. The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population. Methods. We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed. Results. There were 143 patients included in the fittest cohort. Mean age was 66 years (SD 4.5) and 103 were female (72%). No clinically relevant differences were found between the treatment groups in the primary and sensitivity analyses. Conclusion. This analysis found no differences in functional outcomes between HA and THA within two years of displaced low-energy FNF in a subgroup analysis of the fittest HEALTH patients. These findings suggest that very few patients above 50 years of age benefit in a clinically meaningful way from a THA versus a HA early after injury. Cite this article: Bone Jt Open 2022;3(8):611–617

Aims. The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults. Methods. A within-trial economic evaluation was conducted based on data collected from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized controlled trial in the UK. Resource use was measured over 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from the NHS and personal social service perspective. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was represented graphically using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that cemented implants were cost-saving (mean cost difference -£961 (95% confidence interval (CI) -£2,292 to £370)) and increased QALYs (mean QALY difference 0.010 (95% CI 0.002 to 0.017)) when compared to uncemented implants. The probability of the cemented implant being cost-effective approximated between 95% and 97% at alternative cost-effectiveness thresholds held by decision-makers, and its net monetary benefit was positive. The findings remained robust against all the pre-planned sensitivity analyses. Conclusion. This study shows that cemented HA is cost-effective compared with hydroxyapatite-coated uncemented HA in older adults with displaced intracapsular hip fractures. Cite this article: Bone Joint J 2022;104-B(8):922–928

Aims. Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. Methods. Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer’s perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions. Results. DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case. Conclusion. Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients’ physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783–1790

Patients undergoing total hip or knee arthroplasty (THA/TKA) are commonly associated with high pain scores and narcotic use. Duloxetine is effective in relieving chronic pain. The aim of this study was to evaluate the safety and efficacy of duloxetine for pain management following THA/TKA. Five major databases (PubMed, Embase, Scopus, Cochrane, and Web of Science) were searched for randomised controlled trials (RCTs) that compared duloxetine to placebo in patients that underwent THA/TKA. The primary outcome was pain reduction with rest and movement at short-term and long-term time intervals. Secondary outcomes were the use of analgesics, length of stay, and safety profile. The risk of bias was assessed using the Cochrane tool. Data were pooled using RevMan 5.4. The results were reported as mean difference (MD) or standardised MD (SMD) and 95% confidence intervals (CI). Eight RCTs with 767 patients were included. 50.2% (n=385/767) of patients received duloxetine. After one day, duloxetine was superior to the control regarding pain reduction with rest (SMD= −0.22 [−0.41, −0.03], p=0.02) after sensitivity analysis and pain reduction at movement (SMD= −0.39 [−0.55, −0.24], p<0.001). Similarly, after 12 weeks, duloxetine significantly reduced pain with rest (SMD= −0.3 [−0.52, −0.09], p=0.006) and pain with movement (SMD= −0.52 [−0.87, −0.17], p=0.003). In addition, after sensitivity analysis, duloxetine was associated with less analgesic use after one day (MD= −4.65 [−7.3, −2.01], p<0.001) and two days (MD= −5.65 [−10.62, −0.67], p=0.03). Patients who received duloxetine also required fewer analgesics after three days. However, there was no significant difference between the duloxetine and control groups in analgesic use after one week, length of stay, and adverse events. Duloxetine was superior to the placebo regarding short-term and long-term pain reduction with rest and movement following THA/TKA. Duloxetine reduced postoperative analgesic use. There was no significant difference between duloxetine and placebo regarding adverse events and length of stay

Aims. This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. Methods. A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. Results. A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. Conclusion. Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate. Cite this article: Bone Joint Res. 2020;9(5):250–257

Aims. The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. Patients and Methods. A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation. Results. In the base case, patients with a spinal deformity were modelled to have an 8% probability of dislocation following primary THA based on published clinical ranges. Sensitivity analysis revealed that, at its current average price ($1000), DM is cost-effective if it reduces the probability of dislocation to 0.9%. The threshold cost at which DM ceased being cost-effective was $1180, while the ICER associated with a DM THA was $71 000 per QALY. Conclusion. These results indicate that under specific clinical and economic thresholds, DM components are a cost-effective form of treatment for patients with spinal deformity who are at high risk of dislocation after THA. Cite this article: Bone Joint J 2018;100-B:1297–1302

Aim. This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial. Methods. A within-trial cost-utility analysis (CUA) will be conducted at four months postinjury from a health system (National Health Service and personal social services) perspective. Resource use pertaining to healthcare utilization (i.e. inpatient care, physiotherapy, social care, and home adaptations), and utility measures (quality-adjusted life years) will be collected at one and four months (primary outcome endpoint) postinjury; only treatment of complications will be captured at 12 months. Sensitivity analysis will be conducted to assess the robustness of the results. Conclusion. The planned analysis strategy described here records our intent to conduct a within-trial CUA alongside the WHiTE5 trial

Introduction. The purpose of this study is to estimate the cost-effectiveness of performing total hip arthroplasty (THA) versus nonoperative management (NM) in non-obese (BMI 18.5–24.9), overweight (25–29.9), obese (30–34.9), severely-obese (35–39.9), morbidly-obese (40–49.9), and super-obese (50+) patients. Methods. We constructed a state-transition Markov model to compare the cost-utility of THA and NM in the six above-mentioned BMI groups over a 15-year time period. Model parameters for transition probability (i.e. risk of revision, re-revision, death), utility, and costs (inflation adjusted to 2017 US dollars) were estimated from the literature. Direct medical costs of managing hip arthritis were accounted in the model. Indirect societal costs were not included. A 3% annual discount rate was used for costs and utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) of THA versus NM. One-way and Monte Carlo probabilistic sensitivity analysis of the model parameters were performed to determine the robustness of the model. Results. Over the 15-year time period, the ICERs for THA versus NM were: normal-weight ($6,043/QALY), overweight ($5,770/QALY), obese ($5,425/QALY), severely-obese ($7,382/QALY), morbidly-obese ($8,338/QALY), and super-obese ($16,651/QALY). The two highest BMI groups had higher incremental QALYs and incremental costs. The probabilistic sensitivity analysis suggests that THA would be cost-effective in 100% of the normal, overweight, obese, severely-obese, and morbidly-obese simulations, and 99.95% of super-obese simulations at an ICER threshold of $50,000/QALY. Conclusion. Even at a willingness-to-pay threshold of $50,000/QALY, which is considered low for the United States, our model showed that THA would be cost effective for all obesity levels. Therefore, invoking BMI cut-offs for THA may lead to unjustifiable loss of healthcare access for obese patients with end-stage hip osteoarthritis

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Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

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The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR.

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This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening.

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The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics.

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Hip dysplasia (HD) leads to premature osteoarthritis. Timely detection and correction of HD has been shown to improve pain, functional status, and hip longevity. Several time-consuming radiological measurements are currently used to confirm HD. An artificial intelligence (AI) software named HIPPO automatically locates anatomical landmarks on anteroposterior pelvis radiographs and performs the needed measurements. The primary aim of this study was to assess the reliability of this tool as compared to multi-reader evaluation in clinically proven cases of adult HD. The secondary aims were to assess the time savings achieved and evaluate inter-reader assessment.

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The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

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The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days.

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Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA.

Background. Hip resurfacing arthoplasty (HRA) showed promising early and mid-terms results at the beginning of the new millennium. Adverse local tissue reactions associated with metal debris considerably slowed down the implantation of HRA which use is now limited to a few specialized centers. The long term success of this procedure, however, is still largely unknown. This study aimed to provide the clinical results of a series of 400 consecutive HRA with a minimum follow-up of 20 years. Methods. All patients treated with Conserve. ®. Plus HRA between November 1996 and November 2000 were retrospectively selected and 355 patients (400 hips) were included. The clinical results of this series was previously reported in 2004 at a follow up of 2 to 6 years[1]. There were 96 women (27%) and 259 men (73%). Mean age at surgery was 48.2 ± 10.9 years. Long-term survivorship was assessed with Kaplan-Meier survival estimates. UCLA hip scores and SF-12 quality of life scores were collected at follow-up visits. Radiographic positioning of the acetabular component was assessed with the computation of the contact patch to rim (CPR) distance. Radiolucencies about the metaphyseal stem and around the acetabular component were recorded to assess the quality of the component fixation. Results. The mean time of follow up was 16.3 ± 5.5 years including 183 hips beyond 20 yrs. Nine hips were lost to follow up (2.2%) Thirty-three patients (35 hips,8.8%) died of causes unrelated to the surgery at a mean 11.9 ± 5.3 years after surgery The mean UCLA hip scores at last follow-up were 9.3 ± 1.0, 9.1 ± 1.4, 9.0 ± 1.8, and 6.9 ± 1.7 for pain, walking, function, and activity, respectively. Post-operative SF-12 scores were 48.4 ± 10.3 for the physical component and 48.5 ± 15.5 for the mental component and did not differ from those of the general US population. Fifty-five patients (60 hips) underwent revision surgery at a mean time of 9.3 ± 5.8 years. Indications for revision surgery included acetabular component loosening (12 hips), femoral component loosening (31 hips), femoral neck fracture (6 hips), wear (6 hips), sepsis (2 hips), recurrent dislocations (1 hip), acetabular component protrusion after over-reaming (1 hip) and unknown (1 hip which was revised in another center). Using any revision as an endpoint, the Kaplan-Meier survivorship was 95.2% at 5 years, 91.2% at 10 years, 87.3% at 15 years, and 83.2% at 20 years. A multivariate model for risk factor analysis showed a diagnosis of developmental dysplasia (p=0.020) and a low body mass index (typically associated with higher levels of activity) (p=0.032), to be significantly related to revision for any reason. Female sex was not a risk factor after adjustment for hip dysplasia and component size was made (Table 1). There was only 1 femoral failure (a late neck fracture 19 years after surgery) among the hips reconstructed with a cemented metaphyseal stem (n=59). Five of the 6 hips (1.5%) with wear-related failures all had mal-positioned sockets (CPR distance <10mm) and were therefore preventable. There were no cases with a high score of aseptic lymphocytic vasculitis-associated lesions (ALVAL)[2], suggesting metal sensitivity. X-ray analysis showed excellent persisting fixation in all but one hip. Conclusions. In this group of patients operated over 20 years ago, HRA keeps providing excellent pain relief and quality of life to the patients. Subsequent progress in the preparation of the femoral head has considerably reduced the failure rate on the femoral side which was the main mode of failure in this initial series[3, 4]. The 83.1% 20 year survivorship of this initial series surpasses that of total hip arthroplasties in use 20 years ago in this young patient population[5]. Life-long durability of the device is anticipated for most of the remaining patients. The established benefits of this procedure, such as a low dislocation rate, an anatomic reconstruction with physiologic loading of the proximal femur, the absence of taper corrosion, and an easy conversion if ever necessary, make HRA a preferable alternative to THA in young and active patients. For any figures, tables, or references, please contact the authors directly

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The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

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This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum.

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures.