Ceramic bearing fracture is a rare complication following implantation using modern day ceramic bearing materials. Revision bearing options in such cases is debated, with the choice between ceramic-on-ceramic and ceramic-on-polyethylene bearings. Revision to a hard on soft bearing raises concerns about potential catastrophic wear secondary to a third-body reaction caused by the fractured ceramic particles.

Data was collected retrospectively from the NJR, electronic patient records, revision database and picture archiving and communication system. Templating software was used to determine linear wear between first post-operative radiograph and the latest available follow up. Univariate analysis was used to examine patient demographics and the wear rates for revision of ceramic bearing fractures to ceramic on polyethylene components. The intra and inter-rater reliability of wear measurements was calculated.

There were twelve patients identified as meeting the inclusion criteria. The average age at revision was 62 years (54–72). There were 6 liner and 6 head fractures revised to delta ceramic heads and cross-linked polyethylene acetabular components. The most frequently used head size was 32mm. At mean follow up of 3.8 years (0.5 6.1 years), median 4.4 years, linear wear rate was calculated at 0.08± 0.06 mm/year. Both intra-rater and inter-rater reliability was excellent with ICC scores of 0.99 at all timepoints.

Revision to ceramic on polyethylene (CoP) bearings following ceramic fracture does not cause early catastrophic wear at early follow up. It appears safe to use this hard on soft bearing combination, given that wear rates are comparable to what is expected in a primary hip replacement setting. Longer follow up is required to establish if this trend persists.

This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions.

132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05.

There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication.

Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.

Different techniques have been described to address massive bone loss of the acetabulum in revision hip surgery. aMace has gained popularity as it provides customization aiming to restore hip centre and provide good initial stability in cases of large non-contained defects. It takes into account quality of host bone. Its porous defect filling scaffold provides an excellent surface for osteointegration.

Our aim was to assess the short and mid-term outcomes of patients who underwent revision surgery using aMace system.

Ethical approval was obtained. A retrospective study included all patients who had aMace between June 2013 and October 2022 allowing for a minimum of 12-months follow-up. Patients’ demographics, indication, bone-loss severity, reconstruction details, re-operation, complications, mortality, pain and function were assessed.

52 cases were performed by 13 surgeons with median 51 months follow-up. Median age was 72.7 years. 86.5% were female. Average BMI was 25.3. Average ASA grade was 3.

65% were classified as Paprosky IIIB and 32% were IIIA.

73% were found to have poor bone quality on CT. Main indication for aMace was massive bone loss/discontinuity secondary to aseptic loosening in 88.5%.

77% underwent single-stage revision. 53.8% had 2 or more previous revisions. 71% underwent stem revision in the same setting. 77% received a dual mobility bearing.

Re-operation rate was 5.7% for instability and femoral PPF. LLD was reported in 9.6%.

Permanent Sciatic nerve palsy occurred in 3.8% of the cases.

30-days mortality was 1.9%.

Statistically significant post-op improvements in pain and mobility were reported (p<0.001). None of the acetabular components have been revised.

Our study shows satisfactory surgical outcomes with a relatively low complication rate and significant pain and mobility improvements in the early to mid-term stages.

We recommend these costly cases to be done in highly specialist centres adopting MDT approach.

Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health.

An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons.

The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001).

Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons.

Introduction

Osteosynthesis to conserve femoral head following neck of femur (NOF) fractures has reported failure rates of 36 to 47% at 2 years. However, the long-term outcomes of THAs performed for failed osteosynthesis is yet to be elucidated. This study aims to report on long term outcome of primary THAs post failed osteosynthesis for NOF fracture.

Prosthetic joint infection continues to remain a diagnostic challenge for unhappy primary arthroplasty of hip and knees. There is increasing dependence upon alpha-defensin test to make key decisions like whether to revise or not & to decide between one-stage versus two-stage.

Synovasure has been designed and validated for use in the diagnosis of periprosthetic joint infection (PJI). It has a reported sensitivity of 97.4% (CI 86.1–99.6%) and specificity of 95.8% (CI 90.5–98.6%), higher than the variable results reported for aspiration by most units. At a cost of £500 per test, we aimed to establish cost-effectiveness and diagnostic accuracy, to determine its role in routine practice.

We developed a protocol for pre-operative aspiration or intra-operative use. Prerequisites for entry were a high index of clinical suspicion for PJI and equivocal standard investigations. All cases were discussed at the lower limb arthroplasty MDT and approved only if use would change clinical management.

Over 15 months, 36 tests were approved for 22 aspirations (5 hip, 17 knee) and 14 intra-operative cases (7 hip, 7 knee). 10/36 had undergone previous revision surgery. 35/36 cases complied with the protocol. All 22 Synovasure aspirations were negative, corresponding to the microbiology in all but one case; thought to be a contaminant. In the intra-operative group there was one true positive and 12 true negative tests, giving a sensitivity of 100% (95% CI 2.5–100%) and a specificity of 100% (95% CI 73.5–100%). Synovasure influenced decision making in 34/36 procedures. One test failed and in another there was evidence of frank infection. In 11 cases no surgery was performed versus a potential two-stage revision and in 21 cases a single rather than two-stage revision was performed. Resulting in estimated savings of £686,690, offset against a cost of £18,000.

The Synovasure test was found to be sensitive and specific and can aid decision-making particularly in complex cases with an equivocal diagnosis of PJI. The use of this test through a robust protocol driven peer review MDT process not only reduces patient morbidity but drives significant efficiency savings.

Introduction

Primary hip replacement in young active patients is on the increase. Due to the demands set by the patient, implants used in this patient group should have a proven long-term clinical and radiological outcome. We report our results in patients under the age of 50 using the C-Stem femoral component – a cemented triple tapered polished stem.

Introduction

Large acetabular bone defects caused by aseptic loosening are common. Reconstruction of large segmental defects can be challenging. Various implants and operative techniques have been developed to allow further acetabular revision in cases where bone stock is poor. Reconstitution of bone stock is desirable especially in younger patients. The aim of the study was to review the clinical and radiological results of hip revision with structural acetabular bone grafts using fresh frozen allograft and cemented components.

Introduction

Cross linked polyethylene (XLPE) has gained popularity as a bearing surface of choice for younger patients despite only medium term results being available for wear rates. Concern remains regarding the long-term stability and durability of these materials. In order to address these issues we present the longest radiological and clinical follow-up of XLPE.

Introduction

Severe osteolysis of the femur secondary to aseptic loosening in hip arthroplasty, remains a difficult revision scenario. Multiple techniques have been developed to aid the surgeon, including restoration of bone stock with impaction bone grafting or strut allografts, various distal fixation prostheses and mega-prostheses. Cemented femoral components, with integration of the cement into the cavitations, has largely fallen out of favour. We examined the long-term outcomes with this technique.

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit.

A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database.

Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery.

Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction.

ARMD (Adverse Reaction to Metal Debris) is an increasingly recognised complication of metal on metal hip replacements. The MHRA (Medical and Healthcare Related Devices Agency) have advised a blood cobalt or chromium level above 7 mg/L is a threshold for further investigation, stating that “low levels are reassuring and strongly predict not having an adverse outcome”. Cross-sectional imaging should be performed when levels are above 7 mg/L. We have performed a study investigating the specificity and sensitivity of chromium and cobalt metal ion levels as a screening measure for ARMD.

79 ASR hip replacements were performed at our hospital and 75 (95%) of these underwent a Metal Artefact Reduction Sequence (MARS) MRI scan. All patients (64 hips) who had not undergone revision were invited to take part in this study. 57 patients with 62 hip replacements completed hip and activity scores, had blood cobalt and chromium ion level measurements and 3D-CT to measure acetabular component position.

Acetabular component inclination (>50 degrees), small head size (< 51mm) and female gender were significantly correlated with raised chromium (Cr) and cobalt (Co) ion levels. An ARMD was detected using MRI in 18 (29%) of the hips in this study. The incidence of ARMD was significantly higher when chromium concentration was above 7 mg/l (p = 0.02). Chromium ion levels >7 mg/L had a sensitivity of 56% and specificity of 83% for ARMD, and cobalt ion levels >7 mg/L 56% and 76% respectively. 40 patients had cobalt levels <7 mg/L and 33 had chromium levels <7 mg/L, but 8 of these had an ARMD on MRI. All 8 patients had minimal symptoms (Oxford Hip Score ≥ 44 out of 48).

The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended that cobalt and chromium levels be measured in patients with a metal-on-metal hip replacement and cross-sectional imaging performed when these levels are above 7 μg/L. This study has shown that by using this threshold, in patients with this implant combination, the sensitivity and specificity for the detection of ARMD is low and patients with soft tissue disease may be missed. Furthermore the presence of MRI detected ARMD, in the absence of significant clinical symptoms and with metal ion levels <7 μg/L is of concern.

MoM implants at risk of failure are associated with raised cobalt and chromium levels. However metal ion analysis alone is not reliable as a screening tool for ARMD, which is often clinically “silent”. We recommend the routine use of MARS MRI as the safest method of ARMD diagnosis in patients with MoM implants.

Introduction: Although good mid-term results have been reported with some metal on metal hip replacements, reported complications due to metal on metal (MOM) related reactions are a cause for concern. We have assessed the clinical outcome and MRI metallic artefact reduction sequence (MARS) findings in a consecutive series of patients with a large head metal on metal hip replacement.

Methods: 62 ASR XL Corail THRs and 17 ASR resurfacings were performed at our hospital between 2005 and 2008. All patients were reviewed and assessed with an Oxford hip score (OHS), a plain radiograph and a MRI imaging was obtained on 76 (96%) hips. Implant position was assessed using Wrightington cup orientation software.

Results: At a mean follow up of 32 months, 9 (15%) ASR XL Corail THRs, and 2(12%) ASR resurfacings had been revised. 10 revisions were performed for MRI confirmed MOM related pathology. Histology confirmed a MOM reaction in all 10 cases.

Of the 76 hips that were MRI scanned, 27 (36%) had typical features of a MOM reaction. These were classified as mild in 10 (13%), moderate in 13 (17%) and severe in 4 (5%).

78 patients completed an OHS and the mean score was 21. The mean OHS was 29 pre-operatively in those that had been revised, 25 in patients with abnormal MRI findings and 20 in those with a normal MRI. 10 patients with abnormal MRIs had a near perfect OHS (15 or less)

Conclusions: The ASR XL Corail THR has an unacceptably high early failure rate. MARS MRI is able to detect metal debris related soft tissue pathology around metal on metal THRs. These lesions are sometimes asymptomatic. We suggest that MARS MRI evaluation should form part of the routine evaluation of all metal on metal THRs, and in particular of this implant.

From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment.

Objectives: We aimed to assess the incidence of requirement for shoe raises for a leg length discrepancy (LLD) after total hip replacement (THR). We also assessed the patient satisfaction with, and continued use of shoe raises for symptomatic LLD after THR.

Methods: We searched the orthotics records at our institution to identify all patients who had required a shoe raise for symptomatic LLD after primary unilateral total hip replacement between January 2003 and October 2008. 75 patients were identified. 72 were still alive. In the same period 4270 primary hip replacements were carried out at the institution. A questionnaire was sent out to all living patients. Patient details (including satisfaction) and operative details were recorded. Pre-operative and post-operative radiological measurements of leg length discrepancy (LLD) were performed.

Results: The incidence of requirement of a shoe raise for LLD after THR at our institution was 1.8%. 68% were women. 84% of questionnaires were returned. 31% had stopped using their shoe raise completely. Two-thirds of patients found the raise improved their symptoms of a LLD. Symptoms causing dissatisfaction with the shoe raise included new or worsening back pain, limp, uneven walking, self awareness, need to adjust trouser length, pain in other hip, discomfort while walking, and difficulty buying shoes. Patient overall satisfaction with their THR was poor in the patients who were dissatisfied with the shoe raise, but was good in those who found the raise useful.

Conclusion: About 2% of patients may require a shoe raise for symptomatic LLD after THR. Of these 65% will find the shoe raise helpful. Patient with a LLD after a THR that is not helped by a shoe raise are very dissatisfied. It is important that surgeons should take great care to avoid causing a LLD after THR as it can be a cause of very low patient satisfaction.

We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two.

A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection.

A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children’s operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was Staphylococcus aureus, and the tibia was the bone most commonly affected. Polyostotic osteomyelitis occurred in four patients. We believe this is the largest reported series of patients treated for chronic haematogenous osteomyelitis.

Introduction: Leg length discrepancy (LLD) following total hip replacement (THR) is not uncommon. Some patients are symptomatic, with problems such as gait imbalance or back pain. LLD is a potential cause of litigation following THR.

We have observed that some patients perceive their LLD to be much greater than the true LLD. A large LLD is sometimes reported by therapists, despite only a small true LLD.

We have found that abduction tightness is a potent cause of apparent LLD, and report our investigations into this phenomenon.

Method: We have identified a series of patients with abductor tightness and a significant apparent LLD. The LLD becomes apparent when the operated leg is adducted to the midline (or when the patient stands with their ankles together). This causes the contralateral pelvis to elevate and the un-operated leg to “shorten”.

Clinical photographs and videos have been produced to demonstrate this phenomenon.

A 2-dimensional model has been made to demonstrate how the degree of abduction, offset and over-lengthening affect this phenomenon.

A computer model has been used to quantify these effects.

Results: An abduction contracture after THR will cause the un-operated leg to be apparently and functionally short, even in the absence of a true discrepancy.

Even with only minor abductor tightness, increasing the true length will disproportionately increase the apparent LLD.

Conclusion: An abduction contracture is a potent cause of apparent LLD. Even a small degree of true over lengthening will be greatly magnified by this phenomenon. We recommend careful clinical assessment for abductor tightness when examining patients complaining of a LLD after THR.

Purpose of Study: To determine whether pre operative psychological assessment can be used to predict the outcome following intradiscal electro thermal therapy (IDET).

Materials and Methods: Patients undergoing IDET at our unit were asked to complete a pain diagram and a Short Form 36 (SF36) (UK Version 1). Patients were followed up after IDET by means of a postal questionnaire. Patients outcome was assessed using a visual analogue pain score (VAS), an SF36 and a subjective outcome assessment. Pain drawings were classified as organic and non-organic according to the principle described by Mann et al.

Results: Forty-six (80.7%) patients were successfully followed up. Mean age was 41.2 years (range 16–76), 27 were female and 19 male. 73.9% of the pain diagrams were classified as organic and 26.1% as non-organic. The pain diagram was a good predictive tool for outcome following IDET. Patients with ‘organic’ pain drawings showed an improvement in mean pain VAS (pre 6.7, post 5.9), high patient satisfaction (Better 67.6%, Same 11.8%, Worse 20.6%), and higher physical component scores of the SF36 (Physical 64.1, Physical Role 45.6, Pain 54.0) compared to the ‘non-organic’ group who demonstrated a deterioration in mean pain VAS (pre 6.5, post 8.2), low patient satisfaction (Better 8.3%, Same 58.3%, Worse 33.3%), and lower physical component scores of the SF36 (Physical 38.3, Physical Role 20.8, Pain 26.5).

Conclusions: Several authors have shown that certain preoperative psychological characteristics are associated with a poor outcome from spinal surgery. Our findings suggest that pre procedure psychological assessment is useful in predicting which patients will have a favourable outcome from IDET. Pain drawings are quick and easy for patients to complete.

It might be a useful predictor in most of the spine surgery. We have incorporated pain diagrams in the questionnaires of patients undergoing anterior spinal surgery and dynamic stabilisation of spine.

There is concern that intra-articular electrosurgical ablation may cause thermal soft tissue damage, particularly chondrolysis, if excessive temperatures are reached. The aim of this study was to determine whether the intra-articular temperature during arthroscopic subacromial decompression using a monopolar electrosurgical ablator remains below a safe level. Data was collected prospectively from consecutive shoulder arthroscopic subacromial decompressions performed at our institution. Shoulder arthroscopy was performed using three standard portals. Evaluation of the glenohumeral joint and subacromial space was performed in a standard manner. Soft tissue resection of the subacromial bursa was performed using a monopolar electrosurgical ablator probe with continuous integral suction. Additional procedures such as acromioclavicular joint excision and rotator cuff debridement or repair were performed as appropriate. Bone resection, if required was performed using an arthroscopic burr. The temperature of the fluid within the shoulder and subacromial space was continuously monitored using a sterile digital temperature probe. The surgeon performing the procedure was blinded the collection of data. Data from thirty subacromial decompressions has been collected. 8 patients had full thickness cuff tears of which 6 were debrided, and 2 repaired arthroscopically. 13 patients had acromioclavicular joint excision. Mean operating time was 46 minutes (30–107). The infusion pressure ranged from 40 to 65 mmHg. The median volume of infused fluid was 3900 ml (1500 to 9000). The starting temperature ranged from 18.3 to 21.9. The mean maximum temperature reached was 27.6 (range 22.7 to 41.8 °C). The results suggest that the intra-articular temperature is maintained within safe levels when a monopolar electrosurgical ablator with integral suction is used to perform soft tissue subacromial decompression.