Aims

The mechanism by which synovial fluid (SF) kills bacteria has not yet been elucidated, and a better understanding is needed. We sought to analyze the antimicrobial properties of exogenous copper in human SF against Staphylococcus aureus.

Aims

In 2015, we published the results of our ceramic-on-metal (CoM) total hip arthroplasties (THAs) performed between October 2007 and July 2009 with a mean follow-up of 34 months (23 to 45) and a revision rate of 3.1%. The aim of this paper is to present the longer-term outcomes.

Aims

Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care. Cite this article: Bone Joint J 2024;106-B(11):1206–1215

Aims. The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years. Methods. Through our institutional total joint registry, we identified 15,455 primary THAs performed for osteoarthritis from 1990 to 2019. Patients were categorized according to the World Health Organization (WHO) obesity classification and groups were trended over time. Cox proportional hazards regression analysis controlling for confounders was used to investigate the association between year of surgery and two-year risk of any reoperation, any revision, dislocation, periprosthetic joint infection (PJI), venous thromboembolism (VTE), and periprosthetic fracture. Regression was stratified by three separate groups: non-obese; WHO Class I and Class II (BMI 30 to 39 kg/m. 2. ); and WHO Class III patients (BMI ≥ 40 kg/m. 2. ). Results. There was a significant increase in the proportion of all obesity classes from 1990 to 2019, and the BMI values within each WHO class significantly increased over time. Risk of any reoperation did not change over time among non-obese or WHO Class I/II patients, but increased for WHO Class III patients (hazard ratio (HR) 1.04; p = 0.044). Risk of dislocation decreased over time for non-obese (HR 0.96; p < 0.001) and WHO Class I/II (HR 0.96; p = 0.002) patients, but did not change over time for WHO Class III (HR 0.94; p = 0.073) patients. Risks of any revision and PJI did not change over time for any group. Conclusion. The proportion of patients undergoing THA who are obese has increased dramatically at our institution between 1990 and 2019. Despite BMI values increasing within all WHO classes over time, two-year complication risks have remained stable or decreased in WHO Class I/II patients. However, continued efforts will be required to mitigate risks in the heaviest WHO Class III patients. Cite this article: Bone Joint J 2024;106-B(11):1223–1230

Aims. The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy. Methods. We included patients who underwent THA using Wagner Cone due to proximal femur anatomical abnormalities between August 2014 and January 2019 at a single institution. We investigated implant survival time using the endpoint of dislocation and revision, and compared the prevalence of prosthetic impingements between the Wagner Cone, a tapered cone stem, and the Taperloc, a tapered wedge stem, through simulation. We also collected Oxford Hip Score (OHS), visual analogue scale (VAS) satisfaction, and VAS pain by postal survey in August 2023 and explored variables associated with those scores. Results. Of the 58 patients (62 hips), two (two hips) presented with dislocation or reoperation, and Kaplan-Meier analysis indicated a five-year survival rate of 96.7% (95% CI 92.4 to 100). Mean stem anteversion was 35.2° (SD 18.2°) for the Taperloc stem and 29.8° (SD 7.9°) for the Wagner Cone stem; mean reduction from Taperloc to Wagner Cone was 5.4° (SD 18.8°). Overall, 55 hips (52 patients) were simulated, and the prevalence of prosthetic impingement was lower for the Wagner Cone (5.5%, 3/55) compared with the Taperloc (20.0%, 11/55) stem, with an odds ratio of 0.20 (p = 0.038). Among the 33 respondents to the postal survey (36 hips), the mean scores were VAS pain 10.9, VAS satisfaction 86.9, and OHS 44.7. A multivariable analysis revealed that reduction of stem anteversion from Taperloc to Wagner Cone was more favourable for VAS pain (p = 0.029) and VAS satisfaction (p = 0.002). Conclusion. The mid-term survival rate for THA using the Wagner Cone stem was high, which may be supported by a reduction in prosthetic impingement. The reduction in excessive stem anteversion by using a tapered cone stem was associated with reduced pain and increased patient satisfaction. Cite this article: Bone Jt Open 2024;5(10):858–867

Aims

The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.

Aims

Limited implant survival due to aseptic cup loosening is most commonly responsible for revision total hip arthroplasty (THA). Advances in implant designs and materials have been crucial in addressing those challenges. Vitamin E-infused highly cross-linked polyethylene (VEPE) promises strong wear resistance, high oxidative stability, and superior mechanical strength. Although VEPE monoblock cups have shown good mid-term performance and excellent wear patterns, long-term results remain unclear. This study evaluated migration and wear patterns and clinical and radiological outcomes at a minimum of ten years’ follow-up.

The October 2024 Arthroplasty Roundup³⁶⁰ looks at: Breaking the mould: female representation in arthroplasty surgery remains low, with elbow leading the way; Post COVID-19: where are we with the 'catch up' in England and Wales?; Prevalence and clinical impact of sarcopenia in patients undergoing total joint replacement: a systematic review and a meta-analysis; Total joint replacement and sleep: the state of the evidence.

The October 2024 Trauma Roundup³⁶⁰ looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?

The October 2024 Research Roundup³⁶⁰ looks at: Fracture risk among stroke survivors according to post-stroke disability status and stroke type; Noise-induced hearing loss: should surgeons be wearing ear protection during primary total joint replacement?; Intravenous dexamethasone in hip arthroscopy can enhance recovery; Patient-reported outcomes following periprosthetic joint infection of the hip and knee: a longitudinal, prospective observational study; When should surgery take place after weight loss?; Which type of surgery is the hardest physically and mentally?

The October 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Does the primary surgical approach matter when choosing the approach for revision total hip arthroplasty?; Time to achieve the minimal clinically important difference in primary total hip arthroplasty: comparison of anterior and posterior surgical approaches; To scope or not to scope: arthroscopy as an adjunct to PAO does not provide better clinical outcomes at one year than PAO alone; Re-exploring horizons in hip resurfacing: two-year results of a ceramic-on-ceramic hip resurfacing; Association between tranexamic acid and decreased periprosthetic joint infection risk in patients undergoing total hip and knee arthroplasty; Octogenarians fare well: in revision for infection age is not a bar.

The October 2024 Oncology Roundup³⁶⁰ looks at: Composite reconstruction: is it the answer for pelvic resections?; Can the cartilaginous thickness determine the risk of malignancy in pelvic cartilaginous tumours, and how accurate is the preoperative biopsy of these tumours?; Incidence and survival outcomes of patients with high-grade appendicular bone sarcoma and isolated regional lymph node metastasis; Improved metastatic-free survival after systematic re-excision following complete macroscopic unplanned excision of limb or trunk soft-tissue sarcoma; UK guidelines for the management of soft-tissue sarcomas; Current management of desmoid tumours: a review.

Aims. This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices. Methods. Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries. Results. The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices. Conclusion. This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices. Cite this article: Bone Jt Open 2024;5(9):742–748

Aims. The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty. Methods. This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results. The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion. Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients. Cite this article: Bone Joint J 2024;106-B(9):986–993

Aims. The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. Methods. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed. Results. The BOne trauma and Soft-Tissue Injury classification system in total Hip arthroplasty (BOSTI Hip) grades osseous acetabular trauma and periarticular muscle damage during THA. The classification system has an interclass correlation coefficient of 0.90 (95% CI 0.86 to 0.93) for interobserver agreement and 0.89 (95% CI 0.84 to 0.93) for intraobserver agreement. RO THA was associated with improved BOSTI Hip scores (p = 0.002) and more pristine osseous surfaces in the anterior superior (p = 0.001) and posterior superior (p < 0.001) acetabular quadrants compared with CO THA. There were no differences between the groups in relation to injury to the gluteus medius (p = 0.084), obturator internus (p = 0.241), piriformis (p = 0.081), superior gamellus (p = 0.116), inferior gamellus (p = 0.132), quadratus femoris (p = 0.208), and vastus lateralis (p = 0.135), but overall combined muscle injury was reduced in RO THA compared with CO THA (p = 0.023). Discussion. The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. RO THA was associated with improved BOSTI Hip scores, more pristine osseous acetabular surfaces, and reduced combined periarticular muscle injury compared with CO THA. Further research is required to understand if these intraoperative findings translate to differences in clinical outcomes between the treatment groups. Cite this article: Bone Joint J 2024;106-B(9):898–906

Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation.

Cite this article: Bone Joint J 2024;106-B(9):892–897.

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

Aims. Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. Methods. We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA. Results. Robotic-assisted THA resulted in a lower proportion (1.5%) of implant waste compared to navigation-guided THA (2.0%) and manual THA (1.9%) (all p < 0.001). Both navigated and manual THA were more likely to waste acetabular shells (odds ratio (OR) 4.5 vs 3.1) and polyethylene liners (OR 2.2 vs 2.0) compared to robotic-assisted THA after adjusting for demographic and perioperative factors, such as surgeon experience (p < 0.001). While implant waste decreased with increasing experience for procedures performed manually (p < 0.001) or with navigation (p < 0.001), waste rates for robotic-assisted THA did not differ based on surgical experience. Conclusion. Robotic-assisted THAs wasted a smaller proportion of acetabular shells and polyethylene liners than navigation-guided and manual THAs. Individual implant waste rates vary depending on the type of technology used intraoperatively. Future studies on implant waste during THA should examine reasons for non-implantation in order to better understand and develop methods for cost-saving. Cite this article: Bone Jt Open 2024;5(8):715–720

Aims. Precise implant positioning, tailored to individual spinopelvic biomechanics and phenotype, is paramount for stability in total hip arthroplasty (THA). Despite a few studies on instability prediction, there is a notable gap in research utilizing artificial intelligence (AI). The objective of our pilot study was to evaluate the feasibility of developing an AI algorithm tailored to individual spinopelvic mechanics and patient phenotype for predicting impingement. Methods. This international, multicentre prospective cohort study across two centres encompassed 157 adults undergoing primary robotic arm-assisted THA. Impingement during specific flexion and extension stances was identified using the virtual range of motion (ROM) tool of the robotic software. The primary AI model, the Light Gradient-Boosting Machine (LGBM), used tabular data to predict impingement presence, direction (flexion or extension), and type. A secondary model integrating tabular data with plain anteroposterior pelvis radiographs was evaluated to assess for any potential enhancement in prediction accuracy. Results. We identified nine predictors from an analysis of baseline spinopelvic characteristics and surgical planning parameters. Using fivefold cross-validation, the LGBM achieved 70.2% impingement prediction accuracy. With impingement data, the LGBM estimated direction with 85% accuracy, while the support vector machine (SVM) determined impingement type with 72.9% accuracy. After integrating imaging data with a multilayer perceptron (tabular) and a convolutional neural network (radiograph), the LGBM’s prediction was 68.1%. Both combined and LGBM-only had similar impingement direction prediction rates (around 84.5%). Conclusion. This study is a pioneering effort in leveraging AI for impingement prediction in THA, utilizing a comprehensive, real-world clinical dataset. Our machine-learning algorithm demonstrated promising accuracy in predicting impingement, its type, and direction. While the addition of imaging data to our deep-learning algorithm did not boost accuracy, the potential for refined annotations, such as landmark markings, offers avenues for future enhancement. Prior to clinical integration, external validation and larger-scale testing of this algorithm are essential. Cite this article: Bone Jt Open 2024;5(8):671–680

The August 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data.

The August 2024 Knee Roundup³⁶⁰ looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford.

Aims. Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient’s functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA. Methods. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests. Results. A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered. Conclusion. The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation. Cite this article: Bone Joint J 2024;106-B(8):764–774

Aims. Spinopelvic pathology increases the risk for instability following total hip arthroplasty (THA), yet few studies have evaluated how pathology varies with age or sex. The aims of this study were: 1) to report differences in spinopelvic parameters with advancing age and between the sexes; and 2) to determine variation in the prevalence of THA instability risk factors with advancing age. Methods. A multicentre database with preoperative imaging for 15,830 THA patients was reviewed. Spinopelvic parameter measurements were made by experienced engineers, including anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence (PI). Lumbar flexion (LF), sagittal spinal deformity, and hip user index (HUI) were calculated using parameter measurements. Results. With advancing age, patients demonstrate increased posterior APPT, decreased standing LL, decreased LF, higher pelvic incidence minus lumbar lordosis (PI-LL) mismatch, higher prevalence of abnormal spinopelvic mobility, and higher HUI percentage. With each decade, APPT progressed posteriorly 2.1°, LF declined 6.0°, PI-LL mismatch increased 2.9°, and spinopelvic mobility increased 3.8°. Significant differences were found between the sexes for APPT, SPT, SS, LL, and LF, but were not felt to be clinically relevant. Conclusion. With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility. Surgeons should consider the higher prevalence of instability risk factors in elderly patients and anticipate changes evolving in spinopelvic biomechanics for young patients. Cite this article: Bone Joint J 2024;106-B(8):792–801

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

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The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia.

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The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

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Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

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To examine whether natural language processing (NLP) using a clinically based large language model (LLM) could be used to predict patient selection for total hip or total knee arthroplasty (THA/TKA) from routinely available free-text radiology reports.

Aims

In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.

Aims

Periprosthetic fracture and implant loosening are two of the major reasons for revision surgery of cementless implants. Optimal implant fixation with minimal bone damage is challenging in this procedure. This pilot study investigates whether vibratory implant insertion is gentler compared to consecutive single blows for acetabular component implantation in a surrogate polyurethane (PU) model.

The June 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning did not outperform conventional competing risk modelling to predict revision arthroplasty; Unravelling the risks: incidence and reoperation rates for femoral fractures post-total hip arthroplasty; Spinal versus general anaesthesia for hip arthroscopy: a COVID-19 pandemic- and opioid epidemic-driven study; Development and validation of a deep-learning model to predict total hip arthroplasty on radiographs; Ambulatory centres lead in same-day hip and knee arthroplasty success; Exploring the impact of smokeless tobacco on total hip arthroplasty outcomes: a deeper dive into postoperative complications.

The June 2024 Knee Roundup³⁶⁰ looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants.

Aims. The aim of this study was to compare the pattern of initial fixation and changes in periprosthetic bone mineral density (BMD) between patients who underwent total hip arthroplasty (THA) using a traditional fully hydroxyapatite (HA)-coated stem (T-HA group) and those with a newly introduced fully HA-coated stem (N-HA group). Methods. The study included 36 patients with T-HA stems and 30 with N-HA stems. Dual-energy X-ray absorptiometry was used to measure the change in periprosthetic BMD, one and two years postoperatively. The 3D contact between the stem and femoral cortical bone was evaluated using a density-mapping system, and clinical assessment, including patient-reported outcome measurements, was recorded. Results. There were significantly larger contact areas in Gruen zones 3, 5, and 6 in the N-HA group than in the T-HA group. At two years postoperatively, there was a significant decrease in BMD around the proximal-medial femur (zone 6) in the N-HA group and a significant increase in the T-HA group. BMD changes in both groups correlated with BMI or preoperative lumbar BMD rather than with the extent of contact with the femoral cortical bone. Conclusion. The N-HA-coated stem showed a significantly larger contact area, indicating a distal fixation pattern, compared with the traditional fully HA-coated stem. The T-HA-coated stem showed better preservation of periprosthetic BMD, two years postoperatively. Surgeons should consider these patterns of fixation and differences in BMD when selecting fully HA-coated stems for THA, to improve the long-term outcomes. Cite this article: Bone Joint J 2024;106-B(6):548–554

Aims. The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial. Methods. This trial-based economic analysis reports value for money as incremental cost per quality-adjusted life-year (QALY) gained in 2022 Australian dollars, compared to a single threshold value of AUD$70,000 per QALY. Event costs were estimated based on occurrence of VTEs and bleeds, and on published guidelines for treatment. Unit costs were taken from Australian sources. QALYs were estimated using CRISTAL six-month follow-up data. Sensitivity analyses are presented that vary the cost of VTE treatment, and extend the analyses to two years. Results. The CRISTAL trial found that enoxaparin was more effective than aspirin in preventing symptomatic VTE within 90 days of THA or TKA (risk difference 1.97% (95% confidence interval (CI) 0.54% to 3.41%; p = 0.007)). The additional cost after a THA or TKA was AUD$83 (95% CI 68 to 97) for enoxaparin, and enoxaparin resulted in an additional 0.002 QALYs (95% CI -0.002 to 0.005). Incremental cost per QALY gained was AUD$50,567 (95% CI 15,513, dominated) for enoxaparin. We can be 60% confident that the incremental cost per QALY does not exceed the willingness-to-pay threshold of AUD$70,000. Increasing the cost of VTE treatment and extension of costs and consequences to two years suggested greater confidence that enoxaparin is good value for money (70% and 63% confidence, respectively). Conclusion. This analysis provides strong evidence that enoxaparin thromboprophylaxis following THA or TKA reduced VTEs, but weak evidence of net economic benefits over aspirin. If the value of avoiding VTEs is high, and there is a strong likelihood of VTE-related health impairments, we can be more confident that enoxaparin is cost-effective compared to aspirin. Cite this article: Bone Joint J 2024;106-B(6):589–595

Aims. The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years. Methods. The study extends the reporting on the first consecutive 144 resurfacing procedures in 130 patients for all indications. All operations were undertaken between August 1997 and May 1998. The mean age at operation was 52.1 years (SD 9.93; 17 to 76), and included 37 female patients (28.5%). Failure was defined as revision of either component for any reason. Kaplan-Meier survival analysis was performed. Routine follow-up with serum metal ion levels, radiographs, and Oxford Hip Scores (OHSs) was undertaken. Results. Overall implant survival was 83.50% (95% confidence interval (CI) 0.79 to 0.90) at 25 years, and the number at risk was 79. Survival in male patients at 25 years was 89.5% (95% CI 0.83 to 0.96) compared to 66.9% for female patients (95% CI 0.51 to 0.83). Ten additional failures occurred in the period of ten to 25 years. These involved an adverse reaction to metal debris in four patients, a periprosthetic femoral neck fracture affecting five patients, and aseptic loosening in one patient. The median chromium levels were 49.50 nmol/l (interquartile range (IQR) 34 to 70), and the median cobalt serum levels were 42 nmol/l (IQR 24.50 to 71.25). The median OHS at last follow-up was 35 (IQR 10 to 48). During the 25-year study period, 29 patients died. Patient survival at 25 years was 75.10% (95% CI 0.67 to 0.83). Conclusion. This study demonstrates that MoM hip resurfacing using the BHR provides a durable alternative to total hip arthroplasty (THA), particularly in younger male patients with osteoarthritis wishing to maintain a high level of function. These results compare favourably to the best results for THAs. Cite this article: Bone Joint J 2024;106-B(6):540–547

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

Aims. This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years’ clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results. The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion. Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low. Cite this article: Bone Joint J 2024;106-B(6):555–564

Aims. The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses. Results. Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative “worse than death” EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005). Conclusion. More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available. Cite this article: Bone Jt Open 2024;5(5):444–451

Aims

Micromotion of the polyethylene (PE) inlay may contribute to backside PE wear in addition to articulate wear of total knee arthroplasty (TKA). Using radiostereometric analysis (RSA) with tantalum beads in the PE inlay, we evaluated PE micromotion and its relationship to PE wear.

Aims

The objective of this study was to present the outcomes of rotational acetabular osteotomy (RAO) over a 30-year period for osteoarthritis (OA) secondary to dysplasia of the hip in pre- or early-stage OA.

Aims

Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI.

Aims

Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures.

Aims

The purpose of this study was to evaluate the mid-term outcomes of autologous matrix-induced chondrogenesis (AMIC) for the treatment of larger cartilage lesions and deformity correction in hips suffering from symptomatic femoroacetabular impingement (FAI).

Aims. Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA. Methods. A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated. Results. There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time. Conclusion. In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications. Cite this article: Bone Joint J 2024;106-B(5 Supple B):133–138

Aims. Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear. Methods. Data were retrieved for all patients who underwent isolated acetabular component liner exchange surgery with a HXLPE component in our institute between August 2000 and January 2015. Patients were classified according to the fixation method used (original locking mechanism (n = 36) or cemented (n = 50)). Survival and revision rates were compared. A total of 86 revisions were performed and the mean duration of follow-up was 13 years. Results. A total of 20 patients (23.3%) had complications, with dislocation alone being the most common (8.1%; 7/86). Ten patients (11.6%) required re-revision surgery. Cementing the HXLPE liner (8.0%; 4/50) had a higher incidence of re-revision due to acetabular component liner-related complications than using the original locking mechanism (0%; 0/36; p = 0.082). Fixation using the original locking mechanism was associated with re-revision due to acetabular component loosening (8.3%; 3/36), compared to cementing (0%; 0/50; p = 0.038). Overall estimated mean survival was 19.2 years. There was no significant difference in the re-revision rate between the original locking mechanism (11.1%; 4/36) and cementing (12.0%; 6/50; p = 0.899). Using Kaplan-Meier survival analysis, the revision-free survival of HXLPE fixed with the original locking mechanism and cementing was 94.1% and 93.2%, respectively, at ten years, and 84.7% and 81.3%, respectively, at 20 years (p = 0.840). Conclusion. The re-revision rate and the revision-free survival following acetabular component liner exchange revision surgery using the HXLPE liner were not influenced by the fixation technique used. Both techniques were associated with good survival at a mean follow-up of 13 years. Careful patient selection is necessary for isolated acetabular component liner exchange revision surgery in order to achieve the best outcomes. Cite this article: Bone Joint J 2024;106-B(5 Supple B):59–65

Aims

Large bone defects resulting from osteolysis, fractures, osteomyelitis, or metastases pose significant challenges in acetabular reconstruction for total hip arthroplasty. This study aimed to evaluate the survival and radiological outcomes of an acetabular reconstruction technique in patients at high risk of reconstruction failure (i.e. periprosthetic joint infection (PJI), poor bone stock, immunosuppressed patients), referred to as Hip Reconstruction In Situ with Screws and Cement (HiRISC). This involves a polyethylene liner embedded in cement-filled bone defects reinforced with screws and/or plates for enhanced fixation.

Aims

The use of a porous metal shell supported by two augments with the ‘footing’ technique is one solution to manage Paprosky IIIB acetabular defects in revision total hip arthroplasty. The aim of this study was to assess the medium-term implant survival and radiological and clinical outcomes of this technique.