The National Health Service produces over 500,000 tonnes of waste and 25 mega tonnes of CO2 annually. Operating room waste is segregated into different streams which are recycled, disposed of in landfill sites, or undergo costly and energy-intensive incineration processes. By assessing the quantity and recyclability of waste from primary hip and knee arthroplasty cases, we aim to identify strategies to reduce the carbon footprint of arthroplasty surgery. Data was collected prospectively at a tertiary orthopaedic hospital, in the theatres of six arthroplasty surgeons between April – July 2022. Fifteen primary total hip arthroplasty (THA) and 16 primary total knee arthroplasty (TKA) cases were included; revision and complex primary cases were excluded. Waste was categorised into non-hazardous waste, hazardous waste, recycling, sharps, and linens. Each waste category was weighed. Items disposed as non-hazardous waste were catalogued for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined from packaging. Average total waste generated for THA and TKA were 14.46kg and 17.16kg respectively, with TKA generating significantly greater waste (p < 0.05). On average only 5.4% of waste was recycled in TKA and just 2.9% in THA cases. The mean recycled waste was significantly greater in TKA cases compared to THA, 0.93kg and 0.42kg respectively (p < 0.05). Hazardous waste represented the largest proportion of the waste streams for both TKA (69.2%) and THA (73.4%). On average TKA generated a significantly greater amount (11.87kg) compared to THA (10.61kg), p < 0.05. Non-hazardous waste made up 15.1% and 11.3% of total waste for TKA and THA respectively. In the non-hazardous waste, only two items (scrub brush packaging and sterile towel packaging) were identified as recyclable based on packaging. We estimate that annually total hip and knee arthroplasty generates over 2.7 million kg of waste in the UK. Through increased use of recyclable plastics for packaging, combined with clear labelling of items as recyclable, medical suppliers can significantly reduce the carbon footprint of arthroplasty. Our data highlight only a very small percentage of waste is recycled in total hip and knee arthroplasty cases

Introduction. The purpose of the study was to determine access to and, ability to use telemedicine technology in an adult hip and knee reconstruction patient population and we seek to understand these patients' perceived benefits, risks and preferences of telemedicine. Methods. We performed a cross-sectional telephone administered survey on patients scheduled to undergo primary THA and TKA by one of six surgeons at a single academic institution between March 23 and June 2, 2020. Results. 163 patients were contacted and 113 (69.3%) completed the survey. Of the patients that completed surveys, 88% of patients reported using the internet with 94% reporting owning a device capable of videoconferencing. 78% of patients had participated in a video call in the past year and 37% having done a video visit with their physician. When asked for their preferred method for a physician visit, 80% ranked in-person as their first choice, followed by 18% preferring a video visit. Perceived benefits of telemedicine visits included reduced travel to appointments (87% agree or strongly agree) and reduced cost of attending appointments (63% agree or strongly agree). However, patients were concerned that they would not establish the same patient-physician connection (51% agree or strongly agree) and would not receive the same level of care (33% agree or strongly agree) through telemedicine visits versus in person visits. Conclusion. The majority of total hip and knee arthroplasty patients have access to and are capable of using the technology required for telemedicine visits. However, patients still prefer to have in person visit over concern that they will not establish the same patient-physician connection and will not receive the same level of care, despite benefits of reduced time spent traveling to and cost of attending appointments, and making it easier to attend appointments

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

Extensive and severe bone loss of the femur may be a result of a failed total hip arthroplasty (THA) or total knee arthroplasty (TKA) with multiple revision surgeries which may be caused by factors such as infection, periprosthetic fracture or osteolysis. The aim of this study was to assess outcomes of using the “Push-Through Total Femoral Prosthesis” (PTTF) for revision of a total hip replacement with extreme bone loss.

Fourteen patients who had extensive bone defects of the femur due to failed THR's and were treated with PTTF between 2012 and 2020 were included in this study. Primary functional outcomes were assessed using Harris Hip Score (HHS), Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scores. Range of motion, complications, and ambulatory status were also recorded to assess secondary outcomes.

Two of 14 patients underwent surgery with PTTF for both knee and hip arthroplasty revision. The mean time between index surgery and PTTF was 15 years (3 to 32 yrs.). Acetabular components were revised in six of 14 patients. After a mean follow-up of 5.9 years, hip dislocations occurred in 3 patients. All dislocated hips were in patients with retained non-constrained acetabular bearings. Patient satisfaction was high (MSTS: 67%, HHS: 61.2%, TESS 64.6%) despite a high re-operation rate and minor postoperative problems.

PTTF is a unique alternative that may be considered for a failed THA revision procedure in patients with an extreme femoral bone defect. Patients are able to ambulate pain free relatively well. Routine usage of constrained liners should be considered to avoid hip dislocation which was our main problem following the procedure.

The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA).

Patients waiting for a THA (n=100) or KA (n=100) for more than six months were prospectively recruited from the study centre. Overall, 162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected.

There was a significant correlation between CFS and the Oxford score (THA r=ˆ’0.838; p<0.001, KA r=ˆ’0.867; p<0.001), EQ-5D index (THA r=ˆ’0.663, p<0.001; KA r=ˆ’0.681; p< 0.001), and EQ-VAS (THA r=ˆ’0.414; p<0.001, KA r=ˆ’0.386; p<0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p<0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p<0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p<0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p<0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B=ˆ’11.5; p<0.001, KA B=ˆ’7.9; p=0.005) was also associated with CFS.

JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists.

Background

Routine closed suction drainage and postoperative laboratory studies have long been tenets of most TJA protocols. However, recent literature has called into question whether either is necessary with modern outpatient TJA clinical pathways.

Advances in total hip and knee replacement technologies have heretofore been largely driven by corporate marketing hype with each seeming advancement accompanied by a cost increase often out in front of peer-reviewed reports documenting their efficacy or not. As example, consider the growing use of ceramic femoral heads in primary total hip arthroplasty (THA). The question to consider is “Can an upcharge of $350 for a ceramic femoral head in primary THA be justified?” The answer to this question lies in an appreciation of whether the technology modifies the potential for costly revision arthroplasty procedures. Peer-Reviewed Laboratory & Clinical Review - According to the 2022 Australian National Joint Replacement Registry, the four leading causes of primary THA failure requiring revision are: 1.) infection, 2.) dislocation/instability, 3.) periprosthetic fracture and 4.) loosening, which constitute 87.5% of the reported reasons for revision. Focusing on these failure modes, hip simulator findings report that ceramic femoral heads dramatically reduce wear debris generation, decreasing the potential for osteolytic response leading to loosening. Further, ceramic materials enable the utilization of larger head sizes, avoiding the potential for dislocation. The overall mid- to long-term survival rate reported in the peer-reviewed, clinical literature for these bearings has exceeded 95% with virtually no osteolysis. Also, could bearing surface choice influence periprosthetic joint infection (PJI)? A study on a total of more than 10,500 primary THA procedures reported a confirmed PJI incidence of 2.4% for cobalt-chrome and 1.6% for ceramic femoral heads, suggesting that the employ of a ceramic bearing surface may also play a role in decreasing the potential for infection. Review of the clinical data available for ceramic bearings justifies that it is better to “pay me now than to pay orders of magnitude later”, if in fact a revision THA can be avoided, significantly reducing the overall financial burden to the healthcare system

Noise induced hearing loss (NIHL) is a common cause of preventable deafness in adults and exposure to loud noise at work is a significant risk factor for its development. In order to protect the hearing of workers in the U.K., the Health and Safety Executive (HSE), on behalf of the Department for Work and Pensions, established the Control of Noise at Work Regulations (2005). The objectives of this study were to define the levels of noise exposure for the surgeon, assistant, scrub nurse and anaesthetist during total hip and knee arthroplasty surgery. In addition, we sought to determine whether the noise exposure during these procedures reaches or exceeds the action values set out by the U.K. Noise at Work Regulations (2005). To our knowledge no real-time assessment of personal noise exposure has been performed simultaneously on multiple members of the theatre team during arthroplasty surgery. Individual noise exposure during arthroplasty hip and knee surgery was recorded using a personal noise dosemeter system model 22 (DM22) (Pulsar instruments, Filey, U.K.). Recordings were taken real-time during five separate theatre sessions. Each theatre session included two arthroplasty procedures and lasted approximately 4hrs. Personal noise exposure was expressed in terms of peak sound pressure and an average noise exposure over an 8-hour time-period to reflect the noise experienced by the ear over a working day. In all three sessions involving total hip replacement surgery the peak sound pressure, for the operating surgeon, exceeded the exposure action values set out by the U.K. Noise at Work Regulations. Theatre sessions involving total knee replacement surgery did not exceed any exposure action values. The peak sound pressures experienced during total hip replacement surgery are too high and mandate that the surgeon should be provided with appropriate hearing protection. In addition, if the upper exposure action value is routinely exceeded then the theatre should be designated a hearing protection zone

Aims. The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Methods. Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network’s electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019. Results. The PAR captured 16,163 THAs and TKAs between April 2016 and March 2019, performed in seven hospitals by 110 surgeons. Manual comparison to operating schedules showed a 100% capture rate. Review of the records was performed for 2,603 random operations; 2,298 (88.3%) had complete and accurate data. The PAR provided the data for three abstracts presented at international conferences and has led to preoperative mental health treatment as a quality improvement initiative in the participating institutions. For primary THA and TKA surgeries, the LOS decreased significantly (p < 0.001) and the rate of home discharge increased significantly (p < 0.001) between 2016 and 2019. Readmission rates did not correlated with the date of surgery (p = 0.953). Conclusion. The PAR has high rates of coverage (the number of patients treated within the Partners healthcare network) and data completion and can be used for both research purposes and quality improvement. The same method of creating a registry that was used in the PAR can be applied to hospitals using similar EMR systems. Cite this article: Bone Joint J 2020;102-B(7 Supple B):90–98

Introduction. Quality measures play a substantial role in the Centers for Medicare and Medicaid Services' hospital payment and public reporting programs. The purpose of this study was to assess whether public measurement of total hip and knee arthroplasty risk-standardized readmission (RSRRs) and complication rates (RSCRs) was temporally associated with decreasing rates of adverse outcomes among Medicare beneficiaries. Methods. We evaluated annual trends in hospital-level risk-standardized complication and readmission rates in the fiscal years 2010–11 and 2016–17 for patients undergoing hospital-based inpatient hip/knee replacement procedures. We calculated hospital-level rates using the same measures and methodology used in public reporting. We examined annual trends in the distribution of hospital-level outcomes through density plots (similar to histograms). Results. Both rates of and variation in the complication and readmission outcomes declined steadily between 2010–11 and 2016–17. We noted a 33% relative reduction in hospital-level risk-standardized complication rates (RSCRs) and 25% relative reduction in hospital-level risk-standardized readmission rates (RSRRs). The interquartile range of RSCRs decreased by 18% (relative reduction) and of RSRRs decreased by 34% (relative reduction). Risk variable frequency in complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding. Conclusion. This study demonstrates that hospital-level complication and readmission rates after hip/knee replacements and variation in hospital-level performance declined following the start of public reporting and financial incentives associated with measurement. The consistent decreasing trend in rates of and variation outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for hip/knee replacement patients in the years 2016–17 compared to 2010–11. While improvements in surgical practices and care coordination may partially account for these findings, the precise influence of measure public reporting on clinical outcomes is difficult to ascertain. Interactions between public reporting, payment, and hospital coding practices are complex and require continued study

Background. Few studies have compared aspirin with DOACs (direct oral anticoagulants = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis following total hip and knee replacement (THR and TKR). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis following THR and TKR using the world's largest joint replacement registry. Methods. We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THR and TKR patients. Patients receiving aspirin were matched separately to (1) direct thrombin inhibitors, and (2) factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events. Results. Following THR, the risk of VTE was significantly lower in patients receiving direct thrombin inhibitors (0.44%; odds ratio (OR)=0.69, 95% confidence interval (CI)=0.55–0.87, p=0.002) and factor Xa inhibitors (0.37%; OR=0.63, CI=0.47–0.85, p=0.003) compared with aspirin (0.63%). Following THR, direct thrombin inhibitors (coefficient=−0.37, CI=−0.43 to −0.31, p<0.001) and factor Xa inhibitors (coefficient=−0.80, CI=−0.87 to −0.74, p<0.001) reduced length of stay compared with aspirin. Similar findings for both outcomes were observed following TKR. Compared with aspirin, DOACs did not increase the risk of short-term revision surgery; reoperation; major haemorrhage; wound disruption; surgical site infection; and mortality. Conclusions. Following THR and TKR, the risk of VTE was lower in patients receiving DOACs compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs did not increase the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin

Introduction. The Comprehensive Care for Joint Replacement (CJR) initiative was implemented to address the two most commonly billed inpatient surgical procedures, total hip and knee arthroplasty. The primary purpose of this manuscript is to review the economic implications of one institution's mandatory involvement in CJR in comparison to prior involvement in Bundled Payment for Care Improvement (BPCI). Methods. The average cost per episode of care (EOC) was calculated using our institution's historical data. The target prices, projected savings or losses per EOC, and the projected annual savings for both BPCI and CJR were established and comparatively analyzed. Results. The CJR target prices will decrease in comparison to BPCI target prices by: 24% for MS-DRG 469 without fracture, 22.8% for 469 with fracture, 26.1% for 470 without fracture, 27.7% for 470 with fracture; resulting in a reduction in savings per EOC by: 92.8% for MS-DRG 469 without fracture, 166.0% for 469 with fracture, 94.9% for 470 without fracture, 61.7% for 470 with fracture (Table 1). This institution's projected annual savings under CJR will decrease by 83.3%. Conclusion. These results suggest that the margin for savings in CJR will be substantially reduced compared to those in BPCI. Hospitals resources previously devoted will have far less impact in CJR and hospitals new to CJR who have not made these investments previously, will require even greater resources for developing cost-reduction and quality control strategies to remain financially solvent. The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. For any tables or figures, please contact the authors directly

In health care, several studies have suggested worse outcomes in African-Americans. Our objective was to study the relationships of race with outcomes in a series of total hip arthroplasty (THA) cases. A consecutive series of 2,435 total hip/knee arthroplasties (primaries and revisions) performed in a single hospital by a single surgeon were studied. Revisions due to infections were excluded. Data on race was available for 718 THAs which were finally included. Cases of African-Americans (AA) (n=55) and Whites (n=663) were compared on baseline demographics, Charlson, ASA, preoperative-diagnosis; preoperative and postoperative pain intensity/frequency visual-analogue-scale, QWB-7, SF-36, WOMAC, Hip Harris, Postel-D'Aubigne scores; and on postoperative transfusion rates. T-tests, Chi-Square, MANCOVA (age, ethnicity, BMI, and preoperative-diagnosis adjustments) were used. Mean follow-up: 3 years. Alpha was set at 0.05. At baseline and compared to Whites, African-Americans were significantly younger (mean, 67 vs. 59 years), had fewer Hispanics (61% vs. 26%), and had higher BMI (28.5 vs. 30.6 Kg/m. 2. ) (all p≤0.048), respectively. Preoperative diagnoses were significantly different (p<0.001). There were no significant differences between the groups on preoperative scores after adjusting for confounders. Postoperatively, SF-36 bodily-pain (70 vs. 57), SF-36 mental-component-summary (56 vs. 53), WOMAC-total (5 vs. 12), and WOMAC-stiffness (0.14 vs. 0.57) were significantly worse in African-Americans (all p≤0.043), respectively. African-Americans underwent more transfusions (28% vs. 65%, p=0.001). Compared to Whites, African-Americans underwent THA earlier in life, with higher BMI, and different preoperative-diagnosis. They also had worse postoperative scores and more transfusions. Race seems to be strongly associated with outcomes

After total hip and knee replacement arthoplasty, patients may become anaemic and may be prescribed oral iron. There is, however, no published evidence that this is of benefit when used postoperatively. We treated 72 patients who were anaemic after primary total hip and knee arthroplasty by randomly allocating them to receive six weeks of either oral ferrous sulphate (35 patients) or a placebo (37 patients). Both groups of patients were similar in all aspects except for the treatment given. There was no statistically significant difference in the change of haemoglobin levels between the two groups. We therefore believe that the prescription of iron to all anaemic patients postoperatively should be avoided. The level of serum ferritin should be monitored at preoperative assessment

Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in a temporary operating theatre. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates. A total of 1233 primary hip and knee arthroplasties were performed between August 2012 and June 2013. 44% were performed in temporary theatres. The two groups were matched for age, sex, BMI and ASA grade. The deep infection rate for standard operating theatres was 0/684 (0%); for temporary theatres it was 8/539 (1.5%); p=0.001. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty

Aims. The practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed ‘swing room’ in the practice of primary total hip (THA) and knee arthroplasty (TKA). Methods. A retrospective review of prospectively collected data was carried out on patients who underwent primary THA and TKA between 2006 and 2017 in two academic centres. Cases were stratified as partially overlapping (swing room), in which the surgeon is in one operating room (OR) while the next patient is being prepared in another, or nonoverlapping surgery. The demographic details of the patients which were collected included operating time, length of stay (LOS), postoperative complications within six weeks of the procedure, unplanned hospital readmissions, and unplanned reoperations. Fisher's exact, Wilcoxon rank-sum tests, chi-squared tests, and logistic regression analysis were used for statistical analysis. Results. A total of 12,225 cases performed at our institution were included in the study, of which 10,596 (86.6%) were partially overlapping (swing room) and 1,629 (13.3%) were nonoverlapping. There was no significant difference in the mean age, sex, body mass index (BMI), side, and LOS between the two groups. The mean operating time was significantly shorter in the swing room group (58.2 minutes) compared with the nonoverlapping group (62.8 minutes; p < 0.001). There was no significant difference in the rates of complications, readmission and reoperations (p = 0.801 and p = 0.300, respectively) after adjusting for baseline American Society of Anesthesiologists scores. Conclusion. The new ‘swing room’ model yields similar short-term outcomes without an increase in complication rates compared with routine single OR surgery in patients undergoing primary THA or TKA. Cite this article: Bone Joint J 2020;102-B(7 Supple B):112–115

Aims. Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors. Methods. This was an international, multicentre retrospective study of 1,174 revision total hip (THA) and knee arthroplasties (TKA) undergoing I&D for PJI between January 2005 and December 2017. PJI was defined using the Musculoskeletal Infection Society (MSIS) criteria. A total of 52 variables including demographics, comorbidities, and clinical and laboratory findings were evaluated using random forest machine learning analysis. The algorithm was then verified through cross-validation. Results. Of the 1,174 patients that were included in the study, 405 patients (34.5%) failed treatment. Using random forest analysis, an algorithm that provides the probability for failure for each specific patient was created. By order of importance, the ten most important variables associated with failure of I&D were serum CRP levels, positive blood cultures, indication for index arthroplasty other than osteoarthritis, not exchanging the modular components, use of immunosuppressive medication, late acute (haematogenous) infections, methicillin-resistant Staphylococcus aureus infection, overlying skin infection, polymicrobial infection, and older age. The algorithm had good discriminatory capability (area under the curve = 0.74). Cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model. Conclusion. This is the first study in the orthopaedic literature to use machine learning as a tool for predicting outcomes following I&D surgery. The developed algorithm provides the medical profession with a tool that can be employed in clinical decision-making and improve patient care. Future studies should aid in further validating this tool on additional cohorts. Cite this article: Bone Joint J 2020;102-B(7 Supple B):11–19

We cross-matched the Swedish Hip and Knee Arthroplasty Registers (SHAR and SKAR) to study the incidence of knee or hip arthroplasty in any of the remaining hip or knee joints. 177835 THR (55.8% females, mean age, SD: 68.5 10.1 years) and 128162 primary TKR (59.8% females, 69.4 9.0 years) procedures in patients with primary osteoarthritis, performed 1992–2014 were studied. Mean and maximum follow up were 7.7 and 23 years. At the index operation more patients were operated on their right side for both locations (hip and knee). Patients who at the index operation had been operated with a TKR and especially on the left side most frequently (32.5%) received one or several additional TKR or THR. For patients who had a THR at their index operation and underwent a second operation of any of the remaining three joints the mean time to this second procedure was 4.0 years (SD: 3.9). In patients who were operated with a TKR this time period was shorter (3.1, 3.2, p<0.0005). In patients who had undergone their first (index) operation of either hip the probability of not being subjected to further arthroplasty operations during the following 20 years amounted to 64.0±0.3%. The corresponding probability for patients who at the index operation had received a TKR was somewhat lower (58.4±0.4%). Decreasing age (HR: 1.029, 95% confidence interval: 1.028–1.0292), female gender (1.13 1.12–1.15), TKR at index operation (1.34 1.32–1.36) and left-sided index operation (1.12 1.10–1.13) were associated with higher probability for at least one additional primary joint replacement in the hip or the knee. During our period of observation 25 to 33 percent of the patients who received their first total hip or knee replacement underwent at least one additional replacement of either the hip or the knee. Knee osteoarthritis more frequently results in staged bilateral joint replacement than in patients who primarily are suffering from osteoarthritis of the hip

Aims

The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT.

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.