When performing total hip replacement (THR) in high dislocated hips, the presence of soft-tissue contractures means that most surgeons prefer to use a femoral shortening osteotomy in order to avoid the risk of neurovascular damage. However, this technique will sacrifice femoral length and reduce the extent of any leg-length equalisation. We report our experience of 74 THRs performed between 2000 and 2008 in 65 patients with a high dislocated hip without a femoral shortening osteotomy. The mean age of the patients was 55 years (46 to 72) and the mean follow-up was 42 months (12 to 78). All implants were cementless except for one resurfacing hip implant. We attempted to place the acetabular component in the anatomical position in each hip. The mean Harris hip score improved from 53 points (34 to 74) pre-operatively to 86 points (78 to 95) at final follow-up. The mean radiologically determined leg lengthening was 42 mm (30 to 66), and the mean leg-length discrepancy decreased from 36 mm (5 to 56) pre-operatively to 8.5 mm (0 to 18) postoperatively. Although there were four (5%) post-operative femoral nerve palsies, three had fully resolved by six months after the operation. No loosening of the implant was observed, and no dislocations or infections were encountered.

Total hip replacement without a femoral shortening osteotomy proved to be a safe and effective surgical treatment for high dislocated hips.

The April 2013 Hip & Pelvis Roundup³⁶⁰ looks at: hip cartilage and magnets; labral repair or resection; who benefits from injection; rotational osteotomy for osteonecrosis; whether ceramic implants risk fracture; dual articulation; and hydroxyapatite.

We present the development and results of a nationwide, prospective, observational follow-up programme including patient-reported outcome measures (PROMs) for the Swedish Hip Arthroplasty Register. The programme started in 2002 and has gradually expanded to include all units performing total hip replacement in Sweden. The self-administered PROMs protocol comprises the EQ-5D instrument, the Charnley class categorisation and visual analogue scales for pain and satisfaction. These current analyses include 34 960 total hip replacements with complete pre- and one-year post-operative questionnaires.

Patients eligible for total hip replacement generally report low health-related quality of life and suffer from pain. One year post-operatively the mean EQ-5D index increased to above the level of an age- and gender-matched population, with a considerable reduction of pain (p < 0.001). Females, younger patients and those with Charnley category C reported a lower EQ-5D index pre-operatively than males, older patients and Charnley category A or B, respectively (all p < 0.001). In a multivariable regression analysis Charnley category C, male gender and higher age were associated with less improvement in health-related quality of life (p < 0.001).

Nationwide implementation of a PROMs programme requires a structured organisation and effective data capture. Patients’ response rates to the Registry are good. The continuous collection of PROMs permits local and national improvement work and allows for further health-economic evaluation.

The December 2012 Hip & Pelvis Roundup³⁶⁰ looks at: swimming against the tide with resurfacing; hip impingement surgery; the relationship between obesity and co-morbidities and joint replacement infection; cemented hips; cross-linked polyethylene notching; whether cement is necessary in oncological arthroplasty; and how total hip replacement may result in weight gain.

We present a series of 35 patients (19 men and 16 women) with a mean age of 64 years (36.7 to 75.9), who underwent total hip replacement using the ESKA dual-modular short stem with metal on-polyethylene bearing surfaces. This implant has a modular neck section in addition to the modular head. Of these patients, three presented with increasing post-operative pain due to pseudotumour formation that resulted from corrosion at the modular neck-stem junction. These patients underwent further surgery and aseptic lymphocytic vaculitis associated lesions were demonstrated on histological analysis.

Retrieval analysis of two modular necks showed corrosion at the neck-stem taper. Blood cobalt and chromium levels were measured at a mean of nine months (3 to 28) following surgery. These were compared with the levels in seven control patients (three men and four women) with a mean age of 53.4 years (32.1 to 64.1), who had an identical prosthesis and articulation but with a prosthesis that had no modularity at neck-stem junction. The mean blood levels of cobalt in the study group were raised at 50.75 nmol/l (5 to 145) compared with 5.6 nmol/l (2 to 13) in control patients.

Corrosion at neck-stem tapers has been identified as an important source of metal ion release and pseudotumour formation requiring revision surgery. Finite element modelling of the dual modular stem demonstrated high stresses at the modular stem-neck junction. Dual modular cobalt-chrome hip prostheses should be used with caution due to these concerns.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis.

Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10).

Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.

Many different lengths of stem are available for use in primary total hip replacement, and the morphology of the proximal femur varies greatly. The more recently developed shortened stems provide a distribution of stress which closely mimics that of the native femur. Shortening the femoral component potentially comes at the cost of decreased initial stability. Clinical studies on the performance of shortened cemented and cementless stems are promising, although long-term follow-up studies are lacking. We provide an overview of the current literature on the anatomical features of the proximal femur and the biomechanical aspects and clinical outcomes associated with the length of the femoral component in primary hip replacement, and suggest a classification system for the length of femoral stems.

Cite this article: Bone Joint J 2014;96-B:442-8.

We report the long-term survival and functional outcome of the Birmingham Hip Resurfacing (BHR) in patients aged < 50 years at operation, and explore the factors affecting survival. Between 1997 and 2006, a total of 447 BHRs were implanted in 393 patients (mean age 41.5 years (14.9 to 49.9)) by one designing surgeon. The mean follow-up was 10.1 years (5.2 to 14.7), with no loss to follow-up. In all, 16 hips (3.6%) in 15 patients were revised, giving an overall cumulative survival of 96.3% (95% confidence interval (CI) 93.7 to 98.3) at ten years and 94.1% (95% CI 84.9 to 97.3) at 14 years. Using aseptic revision as the endpoint, the survival for men with primary osteoarthritis (n = 195) was 100% (95% CI 100 to 100) at both ten years and 14 years, and in women with primary osteoarthritis (n = 109) it was 96.1% (95% CI 90.1 to 99.9) at ten years and 91.2% (95% CI 68.6 to 98.7) at 14 years. Female gender (p = 0.047) and decreasing femoral head size (p = 0.044) were significantly associated with an increased risk of revision. The median Oxford hip score (OHS, modified as a percentage with 100% indicating worst outcome) at last follow-up was 4.2% (46 of 48; interquartile range (IQR) 0% to 24%) and the median University of California, Los Angeles (UCLA) score was 6.0 (IQR 5 to 8). Men had significantly better OHS (p = 0.02) and UCLA scores (p = 0.01) than women. The BHR provides excellent survival and functional results in men into the second decade, with good results achieved in appropriately selected women.

Cite this article: Bone Joint J 2013;95-B:1172–7.

Excision of the proximal femur for tumour with prosthetic reconstruction using a bipolar femoral head places a considerable load on the unreplaced acetabulum.

We retrospectively reviewed the changes which occur around the affected hip joint by evaluating the post-operative radiographs of 65 consecutive patients who underwent proximal prosthetic arthroplasty of the femur, and in whom an acetabular component had not been used. There were 37 men and 28 women with a mean age of 57.3 years (17 to 93). Radiological assessment included the extent of degenerative change in the acetabulum, heterotopic ossification, and protrusio acetabuli.

The mean follow-up was 9.1 years (2 to 11.8). Degenerative changes in the acetabulum were seen in three patients (4.6%), Brooker grade 1 or 2 heterotopic ossification in 17 (26%) and protrusion of the prosthetic head in nine (13.8%).

A total of eight patients (12.3%) needed a revision. Five were revised to the same type of prosthesis and three (4.6%) were converted to a total hip arthroplasty.

We conclude that radiological evidence of degenerative change, heterotopic ossification and protrusion occur in a few patients who undergo prosthetic arthroplasty of the proximal femur for tumour. The limited extent of these changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in these patients.

Cite this article: Bone Joint J 2015;97-B:1704–9

Arthroscopy of the native hip is an established diagnostic and therapeutic procedure. Its application in the symptomatic replaced hip is still being explored. We describe the use of arthroscopy of the hip in 24 symptomatic patients following total hip replacement, resurfacing arthroplasty of the hip and partial resurfacing (study group), and compared it with arthroscopy of the native hip in 24 patients (control group). A diagnosis was made or confirmed at arthroscopy in 23 of the study group and a therapeutic arthroscopic intervention resulted in relief of symptoms in ten of these. In a further seven patients it led to revision hip replacement. In contrast, arthroscopy in the control group was diagnostic in all 24 patients and the resulting arthroscopic therapeutic intervention provided symptomatic relief in 21.

The mean operative time in the study group (59.7 minutes (35 to 93)) was less than in the control group (71 minutes (40 to 100), p = 0.04) but the arthroscopic approach was more difficult in the arthroplasty group. We suggest that arthroscopy has a role in the management of patients with a symptomatic arthroplasty when other investigations have failed to provide a diagnosis.

We reviewed the outcome of patients who had been treated operatively for symptomatic peri-acetabular metastases and present an algorithm to guide treatment.

The records of 81 patients who had been treated operatively for symptomatic peri-acetabular metastases between 1987 and 2010 were identified. There were 27 men and 54 women with a mean age of 61 years (15 to 87). The diagnosis, size of lesion, degree of pelvic continuity, type of reconstruction, World Health Organization performance status, survival time, pain, mobility and complications including implant failure were recorded in each case.

The overall patient survivorship at five years was 5%. The longest lived patient survived 16 years from the date of diagnosis. The mean survival was 23 months (< 1 to 16 years) and the median was 15 months. At follow-up 14 patients remained alive. Two cementoplasties failed because of local disease progression. Three Harrington rods broke: one patient needed a subsequent Girdlestone procedure. One ‘ice-cream cone’ prosthesis dislocated and was subsequently revised without further problems. We recommend the ‘ice-cream cone’ for pelvic discontinuity and Harrington rod reconstruction for severe bone loss. Smaller defects can be safely managed using standard revision hip techniques.

Cite this article: Bone Joint J 2014;96-B:132–6.

There is a high risk of the development of avascular necrosis of the femoral head and nonunion after the treatment of displaced subcapital fractures of the femoral neck in patients aged < 50 years. We retrospectively analysed the results following fixation with two cannulated compression screws and a vascularised iliac bone graft. We treated 18 women and 16 men with a mean age of 38.5 years (20 to 50) whose treatment included the use of an iliac bone graft based on the ascending branch of lateral femoral circumflex artery. There were 20 Garden grade III and 14 grade IV fractures. Clinical and radiological outcomes were evaluated. The mean follow-up was 5.4 years (2 to 10). In 30 hips (88%) union was achieved at a mean of 4.4 months (4 to 6). Nonunion occurred in four hips (12%) and these patients had a mean age of 46.5 years (42 to 50) and underwent revision to a hip replacement six months after operation. The time to union was dependent on age with younger patients achieving earlier union (p < 0.001). According to the Harris hip score which was available for 27 of the 30 hips with satisfactory union, excellent results were obtained in 15 (score ≥ 90 points), fair in ten (score 80 to 90 points), and poor in two hips (≤ 80 points). One patient aged 48 years developed avascular necrosis of femoral head six years after operation and underwent total hip replacement.

The management of displaced subcapital fractures of the femoral neck, in patients aged <  50 years, with two cannulated compression screws and an iliac bone graft based on the ascending branch of lateral femoral circumflex artery, gives satisfactory results with a low rate of complication including avascular necrosis and nonunion.

Cite this article: Bone Joint J 2014;96-B:1024–8.

This prospective study assessed the effect of social deprivation on the Oxford hip score at one year after total hip replacement. An analysis of 1312 patients undergoing 1359 primary total hip replacements for symptomatic osteoarthritis was performed over a 35-month period. Social deprivation was assessed using the Carstairs index. Those patients who were most deprived underwent surgery at an earlier age (p = 0.04), had more comorbidities (p = 0.02), increased severity of symptoms at presentation (p = 0.001), and were not as satisfied with their outcome (p = 0.03) compared with more affluent patients. There was a significant improvement in Oxford scores at 12 months relative to pre-operative scores for all socioeconomic categories (p < 0.001). Social deprivation was a significant independent predictor of mean improvement in Oxford scores at 12 months, after adjusting for confounding variables (p = 0.001). Deprivation was also associated with an increased risk of dislocation (odds ratio 5.3, p < 0.001) and mortality at 90 days (odds ratio 3.2, p = 0.02).

Outcome, risk of dislocation and early mortality after a total hip replacement are affected by the socioeconomic status of the patient

The February 2013 Hip & Pelvis Roundup³⁶⁰ looks at: amazing alumina; dual mobility; white cells and periprosthetic infection; cartilage and impingement surgery; acetabulum in combination; cementless ceramic prosthesis; metal-on-metal hips; and whether size matters in failure.

We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature.

We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29).

All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p <  0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head.

Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement.

Cite this article: Bone Joint J 2014;96-B:1441–8.

Acetabular bone loss is a challenging problem facing the revision total hip replacement surgeon. Reconstruction of the acetabulum depends on the presence of anterosuperior and posteroinferior pelvic column support for component fixation and stability. The Paprosky classification is most commonly used when determining the location and degree of acetabular bone loss. Augments serve the function of either providing primary construct stability or supplementary fixation.

When a pelvic discontinuity is encountered we advocate the use of an acetabular distraction technique with a jumbo cup and modular porous metal acetabular augments for the treatment of severe acetabular bone loss and associated chronic pelvic discontinuity.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):36–42.

The December 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting

Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.

Peri-acetabular osteotomy is an established surgical treatment for symptomatic acetabular dysplasia in young adults. An anteroposterior radiograph of the pelvis is commonly used to assess the extent of dysplasia as well as to assess post-operative correction. Radiological prognostic factors include the lateral centre-edge angle, acetabular index, extrusion index and the acetabular version. Standing causes a change in the pelvis tilt which can alter certain radiological measurements relative to the supine position. This article discusses the radiological indices used to assess dysplasia and reviews the effects of patient positioning on these indices with a focus on assessment for a peri-acetabular osteotomy. Intra-operatively, fluoroscopy is commonly used and the implications of using fluoroscopy as a modality to assess the various radiological indices along with the effects of using an anteroposterior or posteroanterior fluoroscopic view are examined. Each of these techniques gives rise to a slightly different image of the pelvis as the final image is sensitive to the position of the pelvis and the projection of the x-ray beam.

Cite this article: Bone Joint J 2014;96-B:1155–60.

The December 2012 Trauma Roundup³⁶⁰ looks at: whether tranexamic acid stops bleeding in trauma across the board; antibiotic beads and VAC; whether anaesthetic determines the outcome in surgery for distal radial fractures; high complications in surgery on bisphosphonate-hardened bone; better outcomes but more dislocations in femoral neck fractures; the mythical hip fracture; plate augmentation in nonunion surgery; and SIGN intramedullary nailing and infections.