The December 2013 Hip & Pelvis Roundup. 360 . 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

We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data. The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men. Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care

The femoral head receives blood supply mainly from the deep branch of the medial femoral circumflex artery (MFCA). In previous studies we have performed anatomical dissections of 16 specimens and subsequently visualised the arteries supplying the femoral head in 55 healthy individuals. In this further radiological study we compared the arterial supply of the femoral head in 35 patients (34 men and one woman, mean age 37.1 years (16 to 64)) with a fracture/dislocation of the hip with a historical control group of 55 hips. Using CT angiography, we identified the three main arteries supplying the femoral head: the deep branch and the postero-inferior nutrient artery both arising from the MFCA, and the piriformis branch of the inferior gluteal artery. It was possible to visualise changes in blood flow after fracture/dislocation. Our results suggest that blood flow is present after reduction of the dislocated hip. The deep branch of the MFCA was patent and contrast-enhanced in 32 patients, and the diameter of this branch was significantly larger in the fracture/dislocation group than in the control group (p = 0.022). In a subgroup of ten patients with avascular necrosis (AVN) of the femoral head, we found a contrast-enhanced deep branch of the MFCA in eight hips. Two patients with no blood flow in any of the three main arteries supplying the femoral head developed AVN. Cite this article: Bone Joint J 2013;95-B:1453–7

Direct anterior approaches to the hip have gained popularity as a minimally invasive method when performing primary total hip replacement (THR). A retrospective review of a single institution joint registry was performed in order to compare patient outcomes after THR using the Anterior Supine Intermuscular (ASI) approach versus a more conventional direct lateral approach. An electronic database identified 1511 patients treated with 1690 primary THRs between January 2006 and December 2010. Our results represent a summary of findings from our previously published work. We found that patients that underwent an ASI approach had faster functional recovery and higher Harris hip scores in the early post-operative period when compared with patients who had a direct lateral approach The overall complication rate in our ASI group was relatively low (1.7%) compared with other series using the same approach. The most frequent complication was early periprosthetic femoral fractures (0.9%). The dislocation rate in our series was 0.4% and the prosthetic joint infection rate was 0.1%. We suggest that the ASI approach is acceptable and safe when performing THR and encourages early functional recovery of our patients. Cite this article: Bone Joint J 2014;96- B(11 Suppl A):32–5

We compared 5341 patients with an initial fracture of the hip with 633 patients who sustained a second fracture of the contralateral hip. Patients presenting with a second fracture were more likely to be institutionalised, female, older, and have lower mobility and mental test scores. There was no significant difference between the two groups with regards to the change in the level of mobility or return to their original residence at one year follow-up. However, the mortality rate in the second fracture group was significantly higher at one year (31.6% vs 27.3%, p = 0.024). In two thirds of patients, the second fracture was in the same anatomical location as the first. In an analysis of 293 patients, approximately 70% of second fractures occurred within three years of the first. This is the largest study to investigate the outcome of patients who sustain a second contralateral hip fracture. Despite the higher mortality rate at one year, the outcome for surviving patients is not significantly different from those after initial hip fractures

The purpose of this study was to investigate the development of the osseous acetabular index (OAI) and cartilaginous acetabular index (CAI) using MRI. The OAI and CAI were measured on the coronal MR images of the hip in 81 children with developmental dysplasia of the hip (DDH), with a mean age of 19.6 months (3 to 70), and 241 normal control children with a mean age of 5.1 years (1 month to 12.5 years). Additionally the developmental patterns of the OAI and CAI in normal children were determined by age-based cross-sectional analysis. Unlike the OAI, the normal CAI decreased rapidly from a mean of 10.17° (. sd. 1.60) to a mean of 8.25° (. sd. 1.90) within the first two years of life, and then remained constant at a mean of 8.04° (. sd. 1.65) until adolescence. Although no difference in OAI was found between the uninvolved hips in children with unilateral DDH and normal hips (p = 0.639), the CAI was significantly different between them both (p < 0.001). The normal CAI has fully formed at birth, and is maintained constantly throughout childhood. The CAI in the unaffected hips in children with unilateral DDH is also mildly dysplastic

Aims

Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence.

Salter innominate osteotomy is an effective reconstructive procedure for the treatment of developmental dysplasia of the hip (DDH), but some children have a poor outcome at skeletal maturity. In order to investigate factors associated with an unfavourable outcome, we assessed the development of the contralateral hip. We retrospectively reviewed 46 patients who underwent a unilateral Salter osteotomy at between five and seven years of age, with a mean follow-up of 10.3 years (7 to 20). The patients were divided into three groups according to the centre–edge angle (CEA) of the contralateral hip at skeletal maturity: normal (> 25°, 22 patients), borderline (20° to 25°, 17 patients) and dysplastic (<  20°, 7 patients). The CEA of the affected hip was measured pre-operatively, at eight to nine years of age, at 11 to 12 years of age and at skeletal maturity. The CEA of the affected hip was significantly smaller in the borderline and dysplastic groups at 11 and 12 years of age (p = 0.012) and at skeletal maturity (p = 0.017) than in the normal group. Severin group III was seen in two (11.8%) and four hips (57.1%) of the borderline and dysplastic groups, respectively (p < 0.001). . Limited individual development of the acetabulum was associated with an unfavourable outcome following Salter osteotomy. Cite this article: Bone Joint J 2014;96-B:1419–23

There has been extensive discussion about the effect of delay to surgery on mortality in patients sustaining a fracture of the hip. Despite the low level of evidence provided by many studies, a consensus has been accepted that delay of > 48 hours is detrimental to survival. The aim of this prospective observational study was to determine if early surgery confers a survival benefit at 30 days. Between 1989 and 2013, data were prospectively collected on patients sustaining a fracture of the hip at Peterborough City Hospital. They were divided into groups according to the time interval between admission and surgery. These thresholds ranged from <  6 hours to between 49 and 72 hours. The outcome which was assessed was the 30-day mortality. Adjustment for confounders was performed using multivariate binary logistic regression analysis. In all, 6638 patients aged > 60 years were included. . Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p <  0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality. . Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality. Cite this article: Bone Joint J 2015;97-B:104–8

Aims

Fungal prosthetic joint infections (PJIs) are rare and account for about 1% of total PJIs. Our aim was to present clinical and microbiological results in treating these patients with a two-stage approach and antifungal spacers.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). . This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods. Cite this article: Bone Joint J 2015;97-B:405–11

This paper reviews the current knowledge relating to the management of adult patients with congenital hip disease. Orthopaedic surgeons who treat these patients with a total hip replacement should be familiar with the arguments concerning its terminology, be able to recognise the different anatomical abnormalities and to undertake thorough pre-operative planning in order to replace the hip using an appropriate surgical technique and the correct implants and be able to anticipate the clinical outcome and the complications

The October 2013 Hip & Pelvis Roundup. 360 . looks at: Young and impinging; Clothes, weather and femoral heads?; Go long, go cemented; Surgical repair of the abductors?; Aspirin for DVT prophylaxis?; Ceramic-on-polyethylene: a low-wear solution?; ALVAL and ASR™: the story continues….; Salvaging Legg-Calve-Perthes’ disease

Muscle atrophy has been demonstrated in patients suffering from osteoarthritis of the hip, but little is known about muscular recovery after total hip replacement (THR). A total of 20 patients with unilateral osteoarthritis of the hip were assessed before, six months and two years after THR. The cross-sectional area and radiological density of the muscles of the hip, thigh, calf and back were measured using CT. We hypothesised that the muscles would not recover fully after operation. After two years comparison of the limb with the THR with the healthy limb showed that there was such a reduction in the cross-sectional area in iliopsoas (7.0%; p = 0.006) and the hip adductors (8.4%, p = 0.003) and in the radiological density in gluteus maximus (10.1 Hounsfield units; p < 0.001), gluteus medius/minimus (5.6 Hounsfield units; p = 0.011), iliopsoas (3.9 Hounsfield units; p < 0.001) and the adductors (2.4 Hounsfield units; p = 0.022). Thus, there was persistent muscle atrophy in muscles acting about the hip two years after THR. We suggest that an earlier operation or a more intensive rehabilitation may reverse these changes

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised. Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip

The aim of this study was to examine the rates and potential risk factors for 28-day re-admission following a fracture of the hip at a high-volume tertiary care hospital. We retrospectively reviewed 467 consecutive patients with a fracture of the hip treated in the course of one year. Causes and risk factors for unplanned 28-day re-admissions were examined using univariate and multivariate analysis, including the difference in one-year mortality. A total of 55 patients (11.8%) were re-admitted within 28 days of discharge. The most common causes were pneumonia in 15 patients (27.3%), dehydration and renal dysfunction in ten (18.2%) and deteriorating mobility in ten (18.2%). A moderate correlation was found between chest infection during the initial admission and subsequent re-admission with pneumonia (r = 0.44, p < 0.001). A significantly higher mortality rate at one year was seen in the re-admission group (41.8% (23 of 55) vs 18.7% (77 of 412), p < 0.001). Logistic regression analysis identified advancing age, admission source, and the comorbidities of diabetes and neurological disorders as the strongest predictors for re-admission. Early re-admission following hip fracture surgery is predominantly due to medical causes and is associated with higher one-year mortality. The risk factors for re-admission can have implications for performance-based pay initiatives in the NHS. Multidisciplinary management in reducing post-operative active clinical problems may reduce early re-admission

We report the case of a 74-year-old woman who sustained an intertrochanteric fracture of the femoral neck in a previously arthrodesed hip. The hip arthrodesis had been performed 53 years earlier to treat septic arthritis. The fracture was treated successfully using a double-plating technique with 4.5 mm titanium reconstruction plates

Aims. The aim of this study was to establish the diagnostic accuracy of culture of joint aspirate with and without saline injection-reaspiration. Patients and Methods. This is a retrospective analysis of 580 hip and knee aspirations in patients who were deemed to have a moderate to high risk of infection, and who subsequently proceeded to revision arthroplasty over a period of 12 years. It was carried out at a large quaternary referral centre where preoperative aspiration is routine. Results. Fluid was aspirated primarily in 313 (54%) cases and after saline injection-reaspiration of a ‘dry tap’ in 267 (46%) cases. Overall sensitivity and specificity of the diagnostic aspirate were 84% (78% to 89%) and 85% (81% to 88%), respectively. Sensitivity and specificity of saline injection-reaspiration after ‘dry tap’ were 87% (79% to 92%) and 79% (72% to 84%) compared with 81% (71% to 88%) and 90% (85% to 93%) for direct aspiration. Conclusion. Preoperative joint aspiration and culture is a sensitive and specific test for the confirmation of diagnosis in patients at a moderate to high risk of prosthetic joint infection. Culture of saline injection-reaspiration also provides accurate diagnostic information in the event of a ‘dry tap’. Both methods allow susceptibility testing of relevant organisms and are therefore able to guide perioperative antibiotic therapy. Cite this article: Bone Joint J 2018;100-B:749–54

In 1994, a register for cerebral palsy and a health-care programme were started in southern Sweden with the aim of preventing dislocation of the hip in children with cerebral palsy. It involved all children with cerebral palsy born in 1992 or later. None of the 206 affected children born between 1992 and 1997 has developed a dislocation following the introduction of the prevention programme. Another 48 children moved into the area and none developed any further dislocation. Of the 251 children with cerebral palsy, aged between five and 11 years, living in the area on January 1, 2003, only two had a dislocated hip. One boy had moved into the area at age of nine with a dislocation and a girl whose parents chose not to participate in the programme developed bilateral dislocation. One boy, whose condition was considered to be too poor for preventative surgery, developed a painful dislocation of the hip at the age of five years and died three years later. Eight of 103 children in a control group, consisting of all children with cerebral palsy living in the area between 1994 and 2002, and born between 1990 and 1991, developed a dislocation of the hip before the age of six years. The decreased incidence of dislocation after the introduction of the prevention programme was significant (p < 0.001). Dislocation of the hip in cerebral palsy remains a serious problem, and prevention is important. Our screening programme and early intervention when lateral displacement of the femoral head was detected appear to be successful