Aims. Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. Methods. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. Results. We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. Conclusion. Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care. Cite this article: Bone Joint J 2022;104-B(9):1052–1059

Fixation only of Vancouver B Proximal Femoral Fractures (PFF's), specifically with Cemented Taper Slip stems (CTS) with an intact bone cement interface, has been shown to have reduced blood transfusion requirements and reoperations, compared to revision arthroplasty. This potentially carries the risk of stem subsidence and loosening, which negatively impacts functional outcome. The incidence of stem subsidence and associated fracture morphology have not previously been reported. We retrospectively reviewed all Vancouver B PFF's in primary THR around CTS stems treated with internal fixation only between June 2015 and March 2021 for fracture morphology (Low Spiral (LS), High Spiral (HS), Metaphyseal Split (MS) and Short Oblique (SO)), fracture union and stem subsidence. Interprosthetic fractures and inadequate follow up were excluded. Secondary outcomes were collected. Out of 577 cases on our local periprosthetic database, 134 Vancouver B PFF's around CTS stems were identified, of which 77 patients underwent ORIF only. Of these, 50 procedures were identified, 21 were lost to follow up and 6 patients died before 6 months. Age, mortality rate and ASA is presented. Review of Fracture morphology showed: 100% (3/3) of HS subsided (1 revised for loosening); 68 % (19/28) of MS subsided (1 revised for loosening); 11.1 % (2/18) of LS subsided (0 revised for loosening); 0% (1/1) of SO subsided. There were 2 revisions for non-union (LS group). No dislocations were recorded. There was a statistically significant association between Morphology and Subsidence P value 0.0004). Major subsidence was observed in 8 patients (3 HS, 4 MS and 1 LS) which was associated with a significance reduction in mobility. Subsidence was associated with negative symptoms (P value < 0.0001). Fixation of all Vancouver B PFF's does not produce uniformly good results. Revision rates following ORIF do not fully reflect patient outcomes. This trend will affect the NJR, stem rating and patient satisfaction. Subsidence after ORIF was associated with certain morphologies (HS & MS) and stem revision may be preferrable, in keeping with GIRFT. A morphology-based classification system can inform decision making

The Oxford knee score (OKS) is a validated and widely accepted disease-specific patient-reported outcome measure, but there is limited evidence regarding any long-term trends in the score. We reviewed 5600 individual OKS questionnaires (1547 patients) from a prospectively-collected knee replacement database, to determine the trends in OKS over a ten-year period following total knee replacement. The mean OKS pre-operatively was 19.5 (95% confidence interval (CI) 18.8 to 20.2). The maximum post-operative OKS was observed at two years (mean score 34.4 (95% CI 33.7 to 35.2)), following which a gradual but significant decline was observed through to the ten-year assessment (mean score 30.1 (95% CI 29.1 to 31.1)) (p < 0.001). A similar trend was observed for most of the individual OKS components (p < 0.001). Kneeling ability initially improved in the first year but was then followed by rapid deterioration (p < 0.001). Pain severity exhibited the greatest improvement, although residual pain was reported in over two-thirds of patients post-operatively, and peak improvement in the night pain component did not occur until year four. Post-operative OKS was lower for women (p < 0.001), those aged < 60 years (p < 0.003) and those with a body mass index > 35 kg/m. 2. (p < 0.014), although similar changes in scores were observed. This information may assist surgeons in advising patients of their expected outcomes, as well as providing a comparative benchmark for evaluating longer-term outcomes following knee replacement. Cite this article: Bone Joint J 2013;95-B:45–51

Aims. The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years. Patients and Methods. A descriptive observational study was undertaken using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man between April 2003 and March 2017. All patients aged ≤ 20 years at the time of THA were included and the primary outcome was revision surgery. Descriptive statistics were used to summarize the data and Kaplan–Meier estimates calculated for the cumulative implant survival. Results. A total of 769 THAs were performed in 703 patients. The median follow-up was 5.1 years (interquartile range (IQR) 2.6 to 7.8). Eight patients died and 35 THAs were revised. The use of metal-on-metal (MoM) bearings and resurfacing procedures declined after 2008. The most frequently recorded indications for revision were loosening (20%) and infection (20%), although the absolute risk of these events occurring was low (0.9%). Factors associated with lower implant survival were MoM and metal-on-polyethylene (MoP) bearings and resurfacing arthroplasty (vs ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) bearings, p = 0.002), and operations performed by surgeons who undertook few THAs in this age group as recorded in the NJR (vs those with five or more recorded operations, p = 0.030). Kaplan–Meier estimates showed 96% (95% confidence interval (CI) 94% to 98%) survivorship of implants at five years. Conclusion. Within the NJR, the overall survival for very young patients undergoing THA exceeded 96% during the first five postoperative years. In the absence of studies that can better account for differences in the characteristics of the patients, surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. Cite this article: Bone Joint J 2018;100-B:1320–9

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs. Cite this article: Bone Joint J 2015; 97-B:442–8

Background. The rate of elderly people over 65 year-old increased from 18.5 % in 2004 to 26.0% in 2015 in Japan. Northern part of Japan is a head of the super-aging society, and the rate already reached 30.9% in 2015. Along with aging society, rapid increase of total hip arthroplasties (THA) has been predicted. The aim of this study is to estimate the trend of total hip arthroplasties in our super-aging area in Northern Japan. Methods. Trend on number and rate of THA in one of the local area of leading super-aging society were surveyed in the last decade using the database of diagnostic procedure and surgical records from 2004 to 2015. The cause of revision THA was analyzed in 2004–2009 versus in 2010–2015. Spearman's rank-correlation coefficient and student's t-tests were performed using the PASW 18 software (SPSS Institute Inc). Values of p < 0.05 were considered statistically significant. Results. The data revealed 24,822 cases of orthopaedic surgery, including 4,845 THA from 2004 to 2015. The reason for THA contained 3,343 osteoarthritis (OA, 69 %), 485 traumas (10 %), 291 loosening (6 %). THA increased from 282 cases in 2004 to 450 in 2015 year by year. They contained 3,905 cases of primary THA (81 %), 405 revision THA (8 %), and 535 bipolar hip arthroplasties (11 %). The revision contained 300 aseptic loosening (74 %), and 69 infections (17 %), and 36 dislocations (9%). The value of infections and dislocation as cause of revision THA was larger compared to the value of all revision THA between in 2004–2009 and in 2010–2015 (2.0 and 1.6 times). Discussion. The number and rate of THA increased year by year, because of expansion of elderly people affected by OA in the super-aging society. The number of revision THA due to infections or dislocation may be still increasing year by year

Aim: To assess patient and surgery related factors to identify any trend leading to a stiff TKR. We also looked at the efficacy of MUA in the treatment of a stiff TKR. Material and Methods: Retrospective analysis of TKRs which have undergone MUA during the period from 01/01/1999 to 25/06/2005 at Peterborough Hospitals. We included primary TKRs with a minimum post MUA follow-up of six months. Results: Out of a total of 1809 TKRs, 42 TKRs (2.3%) in 38 patients required MUA. 26 (68%) were females with a median age of 67 years and a median BMI of 30. 34 (81%) had varus knees. Median pre-operative flexion was 100 deg. Median follow-up was 12 months (6 – 45 months). Median pre MUA flexion was 70 deg (15 – 100 deg.). Median surgery to MUA interval was 12 weeks (range: 10 days to 104 wks). Median gain in flexion during MUA was 35 deg (0 – 90 deg). At final follow-up, 74% had lost flexion gained at MUA (median loss: 17.5 deg, mean loss: 20 deg). 71% gained a median of 20 deg flexion with MUA (Mean: 25 deg, range: 15 – 85 deg). Median range of flexion at final follow-up was 90 deg (40 – 120 deg). Conclusion: We were unable to identify any distinct trends in relation to BMI, pre op flexion, other patient or surgical factors that would help predict occurrence of a stiff TKR. We advocate the use of MUA for a stiff TKR. 71% patients gained 20 to 25 deg flexion with MUA. 74% patients lost about 20 deg flexion gained at MUA. The average post MUA flexion at final follow up was 90 deg. This information is useful when counselling patients undergoing MUA. A protocol for management of stiff TKR is suggested

INTRODUCTION. This study is to determine the response of CRP after TKR surgery, both unilateral and simultaneous bilateral TKR. According to the previously published literature from North America and Europe CRP value peaks on the 1. st. and 2. nd. post-operative day and then gradually comes down to normal by 6–8 weeks post-operatively. AIM. To determine the trend of CRP in Indian patients undergoing TKR, both unilateral and simultaneous bilateral TKR. To see whether it follows the trend in North American and European population and to determine whether there is a difference in the CPR pattern in unilateral versus simultaneous bilateral TKR patients. MATERIAL & METHODS. Twenty six patients were included in this study. 13 patients each had unilateral TKR and simultaneous bilateral TKR. All the patients were operated by a single surgeon and assistant. Patients who had Rheumatoid arthritis and post operative adverse events like urinary tract infection were excluded from this study. All 26 patients were female patients and the mean age in the unilateral group was 67 years and in the simultaneous bilateral TKR group was 73 years. CRP levels were measured pre- operatively on 2. nd. day and 8 weeks. TKR was performed in a standard fashion. Both the groups received standard pre and post operative antibiotic prophylaxis. All patients received a posterior stabilized knee implant (Maxx Freedom Knee). RESULTS. In both the groups CRP level shot up on the 2. nd. post-operative day. Although the rise in CRP level was significantly higher in the simultaneous bilateral TKR group as against the unilateral TKR group. This difference was statistically significant. The CRP level came back to normal in about 39% of unilateral TKR patients at 8 weeks post operatively, while in majority (12 out of 13) of bilateral simultaneous TKR patient it was still elevated at 8 weeks post-op and had not come to normal. DISCUSSION. Macrophages are the important in the development of acute phase response namely CRP. The macrophages are present in the bone and bone marrow and less often in the skeletal muscle. The bone and bone marrow injury happening while performing TKR is responsible for elevation of CRP. Various North-American and European studies have shown that the CRP level increases significantly on the 1. st. postoperative day and the decreases from a peak on the 2. nd. postoperative day, attaining normal value at 6 to 8 weeks after operation. The result of our study are in variance to this published literature. Nearly 39% of our unilateral TKR patients and majority all of our simultaneous bilateral TKR patients did not achieve a normal CRP at 8 weeks after operation. These findings are significant as CRP is often used as a very sensitive indicator of post operative joint infection. Hence we conclude that the Indian TKR patients take longer time for the CRP values to become normal and the published literature regarding the normal levels of CRP in Unilateral TKR should not be extrapolated to simultaneous bilateral TKR group

Aims. This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries. Patients and Methods. In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined. Results. During this 17-year period, 62 858 patients were admitted to hospital with a calcaneal fracture. The male-to-female ratio was 2.66:1. The mean annual incidence was 10.5/100 000 for men and 3.8/100 000 for women. The results of the UK HeFT were published in July 2014. The percentage of patients admitted with a calcaneal fracture undergoing internal fixation was 7.31% (3792/51 859) before and 7.38% (534/7229) after its publication. This difference was not statistically significant (p = 0.94). Since 2015, there has been a significant increase in the percentage of calcaneal fractures treated by closed reduction and internal fixation, as opposed to open reduction and internal fixation, from 7.7% (292/3792) to 13.29% (71/534) (p < 0.001). Conclusion. This study documents the epidemiology and trends in surgical treatment of calcaneal fractures in England. We established that surgeons did not change their practice in terms of offering surgery to these patients in response to the results of the UK HeFT. There has been a significant (p < 0.001) increase in the number of calcaneal fractures being treated surgically using less invasive procedures

Aims. The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada. Patients and Methods. Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups. Results. A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009. Conclusion. The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the ‘functional’ non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78–86

Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion. In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001). . In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses. Cite this article: Bone Joint J 2014;96-B:807–16

Background The American Orthopaedic Foot and Ankle Society (AOFAS) score is one scoring system used to evaluate and monitor the progress of patients following foot and ankle surgery. The aim of this study was to evaluate the trend of AOFAS score over a period of time and correlate with quality-adjusted life-year (QALY) score, which is a valid and reliable scoring system. Method All patients undergoing surgery under one foot and ankle surgeon from a period of January 2001 to July 2003 were reviewed. The pre-operative AOFAS and QALY scores and post-operative at 3, 6, 12 months and yearly were collected prospectively. Results This study includes 205 surgical procedures in 159 patients. This included 40 patients with 41 feet in the ankle-hindfoot group; 15 patients with 15 feet in the midfoot group; 83 patients with 114 feet in the hallux group and 29 patients with 35 feet in the lesser toes group. The mean age of the patients was 51.9 yrs. The general trend of the AOFAS graph shows a mean of 45.3 pre-operatively which rises to 72.4 at 3 month and a peak of 77.1 at 6 months only to fall to 75.7 at 12 months. This fall though seemingly marginal was significant (p< 0.001) Kendall’s rank correlation was used to correlate the AOFAS and QALY score. The 6-month AOFAS score was found to have higher correlation with the final QALY score (τ =0.423) than the 12-month AOFAS score (τ =0.236). Conclusion AOFAS score correlates with subjective and functional results as determined by QALY score. The role of assessing AOFAS at 3 months does not seem to be justified. There is a deterioration in score at 12 months. Post-operative scores at 6 months should be sufficient to assess the outcome

Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion.

Introduction. Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Materials & methods. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated. Results. There were 81 pyogenic, 16 tuberculous and 28 postoperative spinal infections. The mean age was 58.4 years (range, 19 to 88 years). There were 71 male and 54 female patients. There were 64 lumbar and 26 thoracic infections. Two level and multi-level spinal infections involving more than two segments occurred in 30 patients. Of sixty positive microbiology yields, the most common organism was methicillin sensitive staphylococcus aureus (n-23) followed by Streptococcal, E Coli and Coagulase negative staphylococcal and Pseudomonas infections. Second biopsy (done when first biopsy negative) was only positive in two patients. Conclusions. Annual incidence of de novo spinal infection was 48 (pyogenic-40, tuberculous-8). The most frequently isolated pathogen was Staphyloccus aureus. Multi-level infection, diabetic patients, resistant TB and postop infection in elderly patients constituted the ‘difficult to treat’ group in our experience. An algorithm for the diagnostic work-up and management of spinal infections is proposed

We explored the trends over time and the geographical variation in the use of subacromial decompression and rotator cuff repair in 152 local health areas (Primary Care Trusts) across England. The diagnostic and procedure codes of patients undergoing certain elective shoulder operations between 2000/2001 and 2009/2010 were extracted from the Hospital Episode Statistics database. They were grouped as 1) subacromial decompression only, 2) subacromial decompression with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95% CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations and the significant increase in the number of procedures being performed in England and elsewhere, there is an urgent need for well-designed clinical trials to determine evidence of clinical effectiveness. Cite this article: Bone Joint J 2014;96-B:70–4

Minimal Invasive Surgery (MIS) in total knee arthroplasty (TKA) has gained much attention in the scientific community and the public in the last few years. There still exists confusion in the related terminology and different surgical techniques are recommended. Cost effectiveness and risk/benefit analysis are not available at the moment. There still remains controversy whether these new techniques represent only a modern trend or the future of TKA. MIS Unicondylar replacement has shown significant faster rehabilitation but the same reproducible radiographic and clinical results compared with the conventional open technique. In Oct 2003 we have started using MIS TKA in our hospital. After a significant learning curve the decision was made to do only MIS TKA from Nov. 2004 up to now. More than 300 cases were performed. Only few definite data are available at this stage. In 20% of the patients we performed the so called quad sparing (QS) technique. This offers a less invasive but very demanding and time consuming approach, where most of the surgery has to be performed from the side using complete new side cutting instruments. In the majority of our patients (80%) we performed a modified mini midvastus (MMI) approach, using standard 4 in 1 front cutting instruments. Electromagnetic navigation (EM) might be a helpful tool for MIS surgery in TKA. We have limited experience with this new EM navigation system in combination with the new MIS TKA surgical techniques. In a pilot study with two groups of patients the direct comparison between QS and MMI was evaluated. Clinical evaluation was performed by two scores (KSS and WOMAC) and five additional functional tests including straight leg raising, active motion, raising a chair, stair climbing and functional gait analysis. Testing was performed pre-op and at 1, 6 and 12 weeks post-op. Patients and investigators were blinded to the surgical technique (either QS or MMI). The average OR time was 92 min (70 to 130) for MMI and 110 (85 to 165) for QS respectively. There were no complications in the MMI and 1 (wound healing) in the QS group. There were no differences in the different scores and in the functional tests between the groups at any time. There is still controversy in the benefit-risk analysis for the different minimal invasive techniques. In our hospital the MIS future for TKA has already started. Patients’ satisfaction and significant earlier rehabilitation are the key advantages of these new surgical techniques. The much easier MMI technique is now the standard. Only in selected cases the more demanding QS technique is performed. According to the learning curve these new MIS techniques are for specialized surgeons only and require additional training programmes. Despite these facts, we do believe that MIS is the future of TKA surgery

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test.

The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100 000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001).

The rates of use of TSA/100 000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p <  0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p <  0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001).

In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes.

Cite this article: Bone Joint J 2015;97-B:1385–9.

Using the General Practice Research Database, we examined the temporal changes in the rates of primary total hip (THR) and total knee (TKR) replacement, the age at operation and the female-to-male ratio between 1991 and 2006 in the United Kingdom.

We identified 27 113 patients with THR and 23 843 with TKR. The rate of performance of THR and TKR had increased significantly (p < 0.0001 for both) during the 16-year period and was greater for TKR, especially in the last five years. The mean age at operation was greater for women than for men and had remained stable throughout the period of study. The female-to-male ratio was higher for THR and TKR and had remained stable.

The data support the notion that the rate of joint replacement is increasing in the United Kingdom with the rate of TKR rising at the highest rate. The perception that the mean age for TKR has decreased over time is not supported.

Introduction. Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011. Methods. Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded. Results. Between 2001 and 2011, 12,684 joint-preserving hip procedures were recorded, of which 5,133 were performed open and 7,551 arthroscopically. The number of arthroscopic hip procedures performed each year increased by 631%, from 263 in 2001, to 1660 in 2011. The number of open procedures performed increased by 271%, from 260 in 2001, to 785 in 2011. The median age-group was 35–39 years of age and 60% of patients were female. There was considerable variation in procedure rates between different Strategic Health Authorities. In 2011, the greatest number of joint-preserving hip procedures were performed in the South West at 9.4 per 100,000 population, whereas the least were performed in the North East at 2.3 per 100,000 population. The proportion of procedures performed arthroscopically was highest in the North West at 75%, and lowest in the East Midlands at 44%. Conclusions. The number of joint-preserving hip procedures performed has risen significantly between 2001 and 2011, with an exponential rise in the number performed arthroscopically since 2006. Well-designed multi-centre clinical trials are essential to justify these relatively new procedures. If this growth continues, these procedures are likely to represent a significant commissioning burden in the future. HES data is limited since it does not include data from the Private Sector