Aims

The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic.

Aims. The purpose of this study was to validate the diagnosis of periprosthetic joint infection (PJI) in the Danish Hip Arthroplasty Register (DHR). Patients and Methods. We identified a cohort of patients from the DHR who had undergone primary total hip arthroplasty (THA) since 1 January 2005 and followed them until first-time revision, death, emigration or until 31 December 2012. Revision for PJI, as registered in the DHR, was validated against a benchmark which included information from microbiology databases, prescription registers, clinical biochemistry registers and clinical records. We estimated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PJI in the DHR alone and in the DHR when combined with microbiology databases. Results. In total, 1382 of the 37 826 primary THAs in the DHR were registered as having been revised for any cause once 26 patients with errors in registration had been excluded: 232 of these were for PJI. For this group, the sensitivity was 67%, specificity 95%, PPV 77%, and NPV 92%. Combining the data from the DHR with those from microbiology databases increased the sensitivity to 90% and also improved specificity (100%), PPV (98%) and NPV (98%). Conclusion. Only two thirds of revisions for PJI were captured in the DHR and only 77% of the PJI reported to the DHR could be confirmed to be infected. . Take home message: combining the data from the DHR with those from microbiology databases substantially improved the validity of the diagnosis of PJI and should enable future register-based studies. Cite this article: Bone Joint J 2016;98-B:320–5

Objectives. To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR. Methods. Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score. Results. The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (. sd. 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012). Conclusions. The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR. Cite this article: Bone Joint Res 2013;2:248–54

Aims

To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications.

Aims

This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty.

We retrospectively reviewed 17 hip arthroplasties in 15 patients having haemodialysis for chronic renal failure. The duration of haemodialysis before the operation averaged 8.6 years and the average age of the patients was 61 years. All patients were followed for more than two years (mean 4.6 years). Six arthroplasties in four patients had failed due to loosening, and one of these patients died from undiagnosed infection of both hips at 7.6 years after the operation. General skeletal abnormalities caused by maintenance haemodialysis may explain the high incidence of loosening and it is important to be aware of the danger of postoperative infection. The risk-to-benefit ratio of hip arthroplasty is high in patients on haemodialysis

We implanted 300 uncoated cementless PM prostheses into 271 patients and followed 251 (92.6%) of them for four to seven years. By then 37 had already been revised for aseptic and three for septic loosening. The survival rate with implant failure as the endpoint was 88.8% for the cup and 85.3% for the stem after six years. There was a higher risk of implant loosening in congenital dysplasia, unilateral hip arthroplasty and obesity. The results of 225 unrevised hip replacements were assessed by questionnaire. Only 27.4% of the patients were completely free from pain and 17.9% had pain on walking any distance or at all times. The walking distance was for less than 30 minutes in 40%. Because of the poor results in comparison with other prostheses we do not recommend further use of the uncoated PM prosthesis

We retrospectively reviewed 45 hip arthroplasties which were performed over a period of 20 years in 38 patients with cirrhosis of the liver. There was a high perioperative 30-day complication rate (26.7%). Advanced cirrhosis was associated with a higher risk of complications (p = 0.004) as also was increased age, a high level of creatinine, a low level of albumin, a low platelet count, ascites, encephalopathy and an increased operative blood loss. The survival of the prosthesis at five years was 77.8% and infection was a major cause of failure. In view of the high rate of early complications and the limited longevity of the prosthesis, surgeons who perform hip arthroplasty on such patients should counsel them appropriately preoperatively

We reviewed retrospectively 25 hip arthroplasties in 25 patients with sickle-cell haemoglobinopathy and osteonecrosis. The mean age of the ten women and 15 men at the onset of hip symptoms was 25 years, and at surgery 30 years (16 to 45); 66% had either SS or S-thal disease, 20% sickle-cell trait, and the remainder SC disease. The mean follow-up was 8.6 years (two to 18). Fourteen (40%) of the arthroplasties had been revised at a mean of 7.5 years after the primary procedure and nine other hips were either radiographically and/or symptomatically loose. The overall complication rate was 49% and the infection rate 20%. The risk-to-benefit ratio of hip arthroplasty in sickle-cell haemoglobinopathy is high

Aims. The pelvis rotates in the sagittal plane during daily activities. These rotations have a direct effect on the functional orientation of the acetabulum. The aim of this study was to quantify changes in pelvic tilt between different functional positions. Patients and Methods. Pre-operatively, pelvic tilt was measured in 1517 patients undergoing total hip arthroplasty (THA) in three functional positions – supine, standing and flexed seated (the moment when patients initiate rising from a seated position). Supine pelvic tilt was measured from CT scans, standing and flexed seated pelvic tilts were measured from standardised lateral radiographs. Anterior pelvic tilt was assigned a positive value. Results. The mean pelvic tilt was 4.2° (-20.5° to 24.5°), -1.3° (-30.2° to 27.9°) and 0.6° (-42.0° to 41.3°) in the three positions, respectively. The mean sagittal pelvic rotation from supine to standing was -5.5° (-21.8° to 8.4°), from supine to flexed seated was -3.7° (-48.3° to 38.6°) and from standing to flexed seated was 1.8° (-51.8° to 39.5°). In 259 patients (17%), the extent of sagittal pelvic rotation could lead to functional malorientation of the acetabular component. Factoring in an intra-operative delivery error of ± 5° extends this risk to 51% of patients. Conclusion. Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics. Optimal orientation is patient-specific and requires an evaluation of functional pelvic tilt pre-operatively. Cite this article: Bone Joint J 2017;99-B:184–91

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

We investigated the incidence of cephalosporin-resistant bacteria in infected hip arthroplasties. Of 740 patients having hip replacement or related procedures performed over three years, 30 had positive bacteriological cultures from tissue removed at the time of surgery. In 18 of the 30 cultures Staphylococcus epidermidis was grown and 12 of these were methicillin-resistant. A prospective study of skin swabs taken from 100 consecutive patients at the time of admission for THR showed methicillin-resistant Staphylococcus epidermidis in 25. This cephalosporin-resistant organism was shown to be the commonest proven cause of infection, and its presence as a skin commensal raises important questions about current antibiotic prophylaxis for joint replacement

The significance of cobalt as a cause of symptoms after McKee hip arthroplasty is discussed. Seven patients are described in whom such arthroplasties became unsatisfactory after periods varying from nine months to four years. Six of these patients were cobalt-positive but nickel-and chrome-negative on patch testing. Macroscopic and histological necrosis of bone, muscle and joint capsule around the prostheses was found in five patients whose hips were explored. The symptoms were progressive pain, a feeling of instability, and in two cases spontaneous dislocation. Radiological features included acetabular fracture, bone resorption, loosening and dislocation of the prosthesis. Increased cobalt concentrations (determined by atomic absorption spectrophotometry) in the urine of four patients and in a variety of tissues in one patient are presented. Patch testing is recommended in the investigation of patients with troublesome McKee hip arthroplasties

Aims

The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA.

Digital radiography is becoming widespread. Accurate pre-operative templating of digital images of the hip traditionally involves positioning a calibration object at its centre. This can be difficult and cause embarrassment. We have devised a method whereby a planar disc placed on the radiographic cassette accounts for the expected magnification. Initial examination of 50 pelvic CT scans showed a mean hip centre distance of 117 mm (79 to 142) above the gluteal skin. Further calculations predicted that a disc of 37.17 mm diameter, placed on the cassette, would appear identical to a 30 mm sphere placed at the level of the centre of the hip as requested by our templating software. We assessed accuracy and reproducibility by ‘reverse calibration’ of 20 radiographs taken three months after hip replacement using simultaneous sphere and disc methods, and a further 20 with a precision disc of accurate size. Even when variations in patient size were ignored, the disc proved more accurate and reliable than the sphere. The technique is reliable, robust, cost effective and acceptable to patients and radiographers. It can easily be used in any radiography department after a few simple calculations and manufacture of appropriately-sized discs

We reviewed the plain radiographs, bone scans and hip aspiration results of 54 patients with painful hip arthroplasties which had been explored surgically, to compare the results of the investigations with the operative findings. For acetabular loosening, the sensitivity and specificity of bone scanning were 87% and 95%, with an accuracy of 90%: for serial plain radiography sensitivity was 95%, specificity 100% and accuracy 97%. For femoral component loosening, bone scan sensitivity was 85%, specificity 100% and accuracy 89%: the sensitivity of plain radiography was 100%, with specificity 92% and accuracy 98%. Technetium bone scanning did not provide additional information with regard to loosening and is not necessary in the routine investigation of a painful hip arthroplasty. Serial pain radiography is the most effective method of detecting loosening, and bone scanning is useful only when radiography is inconclusive with regard to loosening or infection

We have used the Oxford hip score to monitor the progress of 1908 primary and 279 revision hip replacements undertaken since the start of 1995. Our review programme began in early 1999 and has generated 3900 assessments. The mean pre-operative scores for primary and revision cases were 40.95 and 40.11, respectively. The mean annual score for primary replacement at between 12 and 84 months ranged between 20.60 and 22.57. A comparison of cross-sectional and longitudinal data showed no significant differences. All post-operative reviews showed a significant improvement (p ≤ 0.0001). The 50- to 60-year-old group scored significantly better than the patients over 80 years of age up to 48 months (p < 0.01). A subgroup of 826 National Health Service (NHS) and 397 private patients, treated by the senior author (2292 Oxford assessments), had a higher (i.e. worse) mean pre-operative score for the NHS patients (p ≤ 0.001). The private patients scored better than the NHS group up to 84 months (p < 0.05). Patients treated by a surgeon performing more than 100 replacements each year had a significantly better outcome up to five years than those operated on by surgeons performing fewer than 20 replacements each year. The age of the patients at the time of operation, and their pre-operative level of disability, have both been identified as affecting the long-term outcome. Awareness of the influence of these factors should assist surgeons to provide balanced advice

An intra-operative splash is a common occurrence in elective knee and hip replacement surgery and can potentially transmit bloodborne diseases, with devastating consequences. This study aimed to quantify the risk of a splash and to assess its correlation with body mass index, duration of surgery and the volume of lavage fluid used. Between December 2007 and April 2008, 62 consecutive patients (38 women, 24 men) undergoing an elective total knee or total hip replacement (TKR, THR) were recruited into the study (32 TKRs and 30 THRs) after appropriate consent. A splash occurred in all 62 cases. A THR had a slightly higher risk of a splash than a TKR, but this was not statistically significant (p = 0.27). The correlation between body mass index, duration of surgery and the amount of pulse lavage used with a splash was r = 0.013, (non-significant), r = 0.52, (significant) and r = 0.92 (highly significant), respectively. A high number of splashes are generated during a TKR and a THR. The simple visor mask fails to protect the surgeon, the assistant or the patient from the risk of a splash and reverse splash, respectively

The effects of surgical approach in total hip replacement on health-related quality of life and long-term pain and satisfaction are unknown. From the Swedish Hip Arthroplasty Register, we extracted data on all patients that had received a total hip replacement for osteoarthritis through either the posterior or the direct lateral approach, with complete pre- and one-year post-operative Patient Reported Outcome Measures (PROMs). A total of 42 233 patients met the inclusion criteria and of these 4962 also had complete six-year PROM data. The posterior approach resulted in an increased mean satisfaction score of 15 (. sd 19. ) vs 18 (. sd. 22) (p <  0.001) compared with the direct lateral approach. The mean pain score was 13 (. sd 17). vs 15 (. sd. 19) (p < 0.001) and the proportion of patients with no or minimal pain was 78% vs 74% (p < 0.001) favouring the posterior approach. The patients in the posterior approach group reported a superior mean EQ-5D index of 0.79 (. sd 0.23) . vs 0.77 (. sd. 0.24) (p < 0.001) and mean EQ score of 76 (. sd. 20) vs 75 (. sd 20). (p < 0.001). All observed differences between the groups persisted after six years follow-up. Although PROMs after THR in general are very good regardless of surgical approach, the results indicate that some patients operated by the direct lateral approach report an inferior outcome compared with the posterior approach. The large number of procedures and the seemingly sustained differences make it likely these findings are clinically relevant. Cite this article: Bone Joint J 2014;96-B:590–6