Aims. Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery’s outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis. Methods. This single-centre retrospective study included 398 hip joints of patients who underwent THA. Using medical records, we examined preoperative bone mineral density measures of the hip and lumbar spine using dual energy X-ray absorptiometry (DXA) scans and the medications used to treat osteoporosis at the time of admission. We also assessed the following osteoporosis-related biomarkers: tartrate-resistant acid phosphatase 5b (TRACP-5b); total procollagen type 1 amino-terminal propeptide (total P1NP); intact parathyroid hormone; and homocysteine. Results. The prevalence of DXA-proven hip osteoporosis (T-score ≤ -2.5) among THA patients was 8.8% (35 of 398). The spinal osteoporosis prevalence rate was 4.5% (18 of 398), and 244 patients (61.3%; 244 of 398) had osteopenia (-2.5 < T-score ≤ -1) or osteoporosis of either the hip or spine. The rate of pharmacological osteoporosis treatment was 22.1% (88 of 398). TRACP-5b was significantly lower in the osteoporosis-treated group than in the untreated group (p < 0.001). Conclusion. Osteoporosis is common in patients undergoing THA, but the diagnosis and treatment for osteoporosis were insufficient. The lower TRACP-5b levels in the osteoporosis-treated group — that is, osteoclast suppression — may contribute to the reduction of the postoperative revision rate after THA. Cite this article: Bone Joint Res 2022;11(12):873–880

Aims. This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters. Patients and Methods. A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility. Results. Standing to sitting, the hip flexed by a mean of 57° (. sd. 17°), the pelvis tilted backwards by a mean of 20° (. sd. 12°), and the lumbar spine flexed by a mean of 20° (. sd. 14°); strong correlations were detected. There was no difference in PROMs between patients in the different spinopelvic mobility groups. Maximum hip flexion, standing PT, and standing AI were independent predictors of spinopelvic mobility (R. 2. = 0.42). The combined thresholds for standing was PT ≥ 13° and hip flexion ≥ 88° in the clinical examination, and had 90% sensitivity and 63% specificity of predicting spinopelvic stiffness, while SS ≥ 42° had 84% sensitivity and 67% specificity of predicting spinopelvic hypermobility. Conclusion. The hip, on average, accounts for three-quarters of the standing-to-sitting movement, but there is great variation. Abnormal spinopelvic mobility cannot be screened with PROMs. However, clinical and standing radiological features can predict spinopelvic mobility with good enough accuracy, allowing them to be used as reliable screening tools. Cite this article: Bone Joint J 2019;101-B:902–909

Aims. Adverse spinal motion or balance (spine mobility) and adverse pelvic mobility, in combination, are often referred to as adverse spinopelvic mobility (SPM). A stiff lumbar spine, large posterior standing pelvic tilt, and severe sagittal spinal deformity have been identified as risk factors for increased hip instability. Adverse SPM can create functional malposition of the acetabular components and hence is an instability risk. Adverse pelvic mobility is often, but not always, associated with abnormal spinal motion parameters. Dislocation rates for dual-mobility articulations (DMAs) have been reported to be between 0% and 1.1%. The aim of this study was to determine the early survivorship from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of patients with adverse SPM who received a DMA. Methods. A multicentre study was performed using data from 227 patients undergoing primary total hip arthroplasty (THA), enrolled consecutively. All the patients who had one or more adverse spine or pelvic mobility parameter had a DMA inserted at the time of their surgery. The mean age was 76 years (22 to 93) and 63% were female (n = 145). At a mean of 14 months (5 to 31) postoperatively, the AOANJRR was analyzed for follow-up information. Reasons for revision and types of revision were identified. Results. The AOANJRR reported two revisions: one due to infection, and the second due to femoral component loosening. No revisions for dislocation were reported. One patient died with the prosthesis in situ. Kaplan-Meier survival rate was 99.1% (95% confidence interval 98.3 to 100) at 14 months (number at risk 104). Conclusion. In our cohort of patients undergoing primary THA with one or more factor associated with adverse SPM, DM bearings conferred stability at two years’ follow-up. Cite this article: Bone Joint J 2022;104-B(7):820–825

Aims. The purpose of this study was to evaluate spinopelvic mechanics from standing and sitting positions in subjects with and without femoroacetabular impingement (FAI). We hypothesize that FAI patients will experience less flexion at the lumbar spine and more flexion at the hip whilst changing from standing to sitting positions than subjects without FAI. This increase in hip flexion may contribute to symptomatology in FAI. Patients and Methods. Male subjects were prospectively enrolled to the study (n = 20). Mean age was 31 years old (22 to 41). All underwent clinical examination, plain radiographs, and dynamic imaging using EOS. Subjects were categorized into three groups: non-FAI (no radiographic or clinical FAI or pain), asymptomatic FAI (radiographic and clinical FAI but no pain), and symptomatic FAI (patients with both pain and radiographic FAI). FAI was defined as internal rotation less than 15° and alpha angle greater than 60°. Subjects underwent standing and sitting radiographs in order to measure spine and femoroacetabular flexion. Results. Compared with non-FAI controls, symptomatic patients with FAI had less flexion at the spine (mean 22°, . sd. 12°, vs mean 35°, . sd. 8°; p = 0.04) and more at the hip (mean 72°, . sd. 6°, vs mean 62°, . sd. 8°; p = 0.047). Subjects with asymptomatic FAI had more spine flexion and similar hip flexion when compared to symptomatic FAI patients. Both FAI groups also sat with more anterior pelvic tilt than control patients. There were no differences in standing alignment among groups. Conclusion. Symptomatic patients with FAI require more flexion at the hip to achieve sitting position due to their inability to compensate through the lumbar spine. With limited spine flexion, FAI patients sit with more anterior pelvic tilt, which may lead to impingement between the acetabulum and proximal femur. Differences in spinopelvic mechanics between FAI and non-FAI patients may contribute to the progression of FAI symptoms. Cite this article: Bone Joint J 2018;100-B:1275–9

Aims. Cross-table lateral (CTL) radiographs are commonly used to measure acetabular component anteversion after total hip arthroplasty (THA). The CTL measurements may differ by > 10° from CT scan measurements but the reasons for this discrepancy are poorly understood. Anteversion measurements from CTL radiographs and CT scans are compared to identify spinopelvic parameters predictive of inaccuracy. Methods. THA patients (n = 47; 27 males, 20 females; mean age 62.9 years (SD 6.95)) with preoperative spinopelvic mobility, radiological analysis, and postoperative CT scans were retrospectively reviewed. Acetabular component anteversion was measured on postoperative CTL radiographs and CT scans using 3D reconstructions of the pelvis. Two cohorts were identified based on a CTL-CT error of ≥ 10° (n = 11) or < 10° (n = 36). Spinopelvic mobility parameters were compared using independent-samples t-tests. Correlation between error and mobility parameters were assessed with Pearson’s coefficient. Results. Patients with CTL error > 10° (10° to 14°) had stiffer lumbar spines with less mean lumbar flexion (38.9°(SD 11.6°) vs 47.4° (SD 13.1°); p = 0.030), different sagittal balance measured by pelvic incidence-lumbar lordosis mismatch (5.9° (SD 18.8°) vs -1.7° (SD 9.8°); p = 0.042), more pelvic extension when seated (pelvic tilt -9.7° (SD 14.1°) vs -2.2° (SD 13.2°); p = 0.050), and greater change in pelvic tilt between supine and seated positions (12.6° (SD 12.1°) vs 4.7° (SD 12.5°); p = 0.036). The CTL measurement error showed a positive correlation with increased CTL anteversion (r = 0.5; p = 0.001), standing lordosis (r = 0.23; p = 0.050), seated lordosis (r = 0.4; p = 0.009), and pelvic tilt change between supine and step-up positions (r = 0.34; p = 0.010). Conclusion. Differences in spinopelvic mobility may explain the variability of acetabular anteversion measurements made on CTL radiographs. Patients with stiff spines and increased compensatory pelvic movement have less accurate measurements on CTL radiographs. Flexion of the contralateral hip is required to obtain clear CTL radiographs. In patients with lumbar stiffness, this movement may extend the pelvis and increase anteversion of the acetabulum on CTL views. Reliable analysis of acetabular component anteversion in this patient population may require advanced imaging with a CT scan. Cite this article: Bone Joint J 2021;103-B(7 Supple B):59–65

Aims. Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning. Methods. A total of 54 patients with distal radial fractures were included in the study. Each underwent posteroanterior (PA) and lateral radiographs of the injured wrist with an aluminium step wedge. Overall 27 patients underwent routine DXA scanning of the hip and lumbar spine, with 13 undergoing additional DXA scanning of the uninjured forearm. Analysis of radiographs was performed on ImageJ and Matlab with calculations of cortical measures, cortical indices, combined cortical scores, and aluminium equivalent grading. Results. Cortical measures showed varying correlations with the forearm DXA results (range: Pearson correlation coefficient (r) = 0.343 (p = 0.251) to r = 0.521 (p = 0.068)), with none showing statistically significant correlations. Aluminium equivalent grading showed statistically significant correlations with the forearm DXA of the corresponding region of interest (p < 0.017). Conclusion. Cortical measures, cortical indices, and combined cortical scores did not show a statistically significant correlation to forearm DXA measures. Aluminium-equivalent is an easily applicable method for estimation of BMD from digital radiographs in the preoperative setting. Cite this article: Bone Joint Res 2021;10(12):830–839

Aims. The complex relationship between acetabular component position and spinopelvic mobility in patients following total hip arthroplasty (THA) renders it difficult to optimize acetabular component positioning. Mobility of the normal lumbar spine during postural changes results in alterations in pelvic tilt (PT) to maintain the sagittal balance in each posture and, as a consequence, markedly changes the functional component anteversion (FCA). This study aimed to investigate the in vivo association of lumbar degenerative disc disease (DDD) with the PT angle and with FCA during postural changes in THA patients. Methods. A total of 50 patients with unilateral THA underwent CT imaging for radiological evaluation of presence and severity of lumbar DDD. In all, 18 patients with lumbar DDD were compared to 32 patients without lumbar DDD. In vivo PT and FCA, and the magnitudes of changes (ΔPT; ΔFCA) during supine, standing, swing-phase, and stance-phase positions were measured using a validated dual fluoroscopic imaging system. Results. PT, FCA, ΔPT, and ΔFCA were significantly correlated with the severity of lumbar DDD. Patients with severe lumbar DDD showed marked differences in PT with changes in posture; there was an anterior tilt (-16.6° vs -12.3°, p = 0.047) in the supine position, but a posterior tilt in an upright posture (1.0° vs -3.6°, p = 0.005). A significant decrease in ΔFCA during stand-to-swing (8.6° vs 12.8°, p = 0.038) and stand-to-stance (7.3° vs 10.6°,p = 0.042) was observed in the severe lumbar DDD group. Conclusion. There were marked differences in the relationship between PT and posture in patients with severe lumbar DDD compared with healthy controls. Clinical decision-making should consider the relationship between PT and FCA in order to reduce the risk of impingement at large ranges of motion in THA patients with lumbar DDD. Cite this article: Bone Joint J 2020;102-B(11):1505–1510

Aims. Previous research has demonstrated increased early complication rates following total hip arthroplasty (THA) in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth (FD) has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery, as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peritrochanteric FD was associated with an increased risk of complications in the first year following THA. Methods. We analyzed prospectively collected data on a consecutive series of 1,220 primary THAs from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured intraoperatively using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient’s preoperative assessment. All surgical complications occuring within the initial 12 months of follow-up were identified. Results. Females had a significantly greater FD at the greater trochanter in comparison to males (median 3.0 cm (interquartile range (IQR) 2.3 to 4.0) vs 2.0 cm (IQR 1.7 to 3.0); p < 0.001) despite equivalent BMI between sexes (male median BMI 30.0 kg/m. 2. (IQR 27.0 to 33.0); female median 29.0 kg/m. 2. (IQR 25.0 to 33.0)). FD showed a weak correlation with BMI (R² 0.41 males and R² 0.43 females). Patients with the greatest FD (upper quartile) were at no greater risk of complications compared with patients with the lowest FD (lower quartile); 7/311 (2.3%) vs 9/439 (2.1%); p = 0.820 . Conversely, patients with the highest BMI (≥ 40 kg/m. 2. ) had a significantly increased risk of complications compared with patients with lower BMI (< 40 kg/m. 2. ); 5/60 (8.3% vs 18/1,160 (1.6%), odds ratio (OR) 5.77 (95% confidence interval (CI) 2.1 to 16.1; p = 0.001)). Conclusion. We found no relationship between peritrochanteric FD and the risk of surgical complications following primary THA. Cite this article: Bone Joint J 2020;102-B(9):1146–1150

Aims. The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position. Patients and Methods. A total of 161 patients were considered for inclusion. Patients had a mean age of the remaining 61 years (. sd. 11) with a mean body mass index (BMI) of 28 kg/m. 2. (. sd. 6). Of the 161 patients, 82 were male (51%). We excluded 17 patients (11%) with spinal conditions known to affect lumbar mobility as well as the rotational axis of the spine. Standing and sitting spine-to-lower-limb radiographs were taken of the remaining 144 patients before and one year following THA. Spinopelvic alignment measurements, including sacral slope, lumbar lordosis, and pelvic incidence, were measured. These angles were used to calculate lumbar spine flexion and femoroacetabular hip flexion from a standing to sitting position. A radiographic scoring system was used to identify those patients in the series who had lumbar degenerative disc disease (DDD) and compare spinopelvic parameters between those patients with DDD (n = 38) and those who did not (n = 106). Results. Following THA, patients sat with more anterior pelvic tilt (mean increased sacral slope 18° preoperatively versus 23° postoperatively; p = 0.001) and more lumbar lordosis (mean 28° preoperatively versus 35° postoperatively; p = 0.001). Preoperative change in sacral slope from standing to sitting (p = 0.03) and the absence of DDD (p = 0.001) correlated to an increased change in postoperative sitting pelvic alignment. Conclusion. Sitting lumbar-pelvic-femoral alignment following THA may be driven by hip arthritis and/or spinal deformity. Patients with DDD and fixed spinopelvic alignment have a predictable pelvic position one year following THA. Patients with normal spines have less predictable postoperative pelvic position, which is likely to be driven by hip stiffness. Cite this article: Bone Joint J 2018;100-B:1289–96

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed. Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31). In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance

Aims

It has been well documented in the arthroplasty literature that lumbar degenerative disc disease (DDD) contributes to abnormal spinopelvic motion. However, the relationship between the severity or pattern of hip osteoarthritis (OA) as measured on an anteroposterior (AP) pelvic view and spinopelvic biomechanics has not been well investigated. Therefore, the aim of the study is to examine the association between the severity and pattern of hip OA and spinopelvic motion.

Aims

The aim of this study was to evaluate the reliability and validity of a patient-specific algorithm which we developed for predicting changes in sagittal pelvic tilt after total hip arthroplasty (THA).

Aims

This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

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.

Aims

Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury.

Aims

The risk factors for abnormal spinopelvic mobility (SPM), defined as an anterior rotation of the spinopelvic tilt (∆SPT) ≥ 20° in a flexed-seated position, have been described. The implication of pelvic incidence (PI) is unclear, and the concept of lumbar lordosis (LL) based on anatomical limits may be erroneous. The distribution of LL, including a unusual shape in patients with a high lordosis, a low pelvic incidence, and an anteverted pelvis seems more relevant.

Aims

The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

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.

Aims

Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA.

Aims

BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems.

Aims

Pelvic tilt is believed to affect the symptomology of osteoarthritis (OA) of the hip by alterations in joint movement, dysplasia of the hip by modification of acetabular cover, and femoroacetabular impingement by influencing the impingement-free range of motion. While the apparent role of pelvic tilt in hip pathology has been reported, the exact effects of many forms of treatment on pelvic tilt are unknown. The primary aim of this study was to investigate the effects of surgery on pelvic tilt in these three groups of patients.

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Aims

Pelvic incidence (PI) is a position-independent spinopelvic parameter traditionally used by spinal surgeons to determine spinal alignment. Its relevance to the arthroplasty surgeon in assessing patient risk for total hip arthroplasty (THA) instability preoperatively is unclear. This study was undertaken to investigate the significance of PI relative to other spinopelvic parameter risk factors for instability to help guide its clinical application.

Aims

Interleukin (IL)-1β is one of the major pathogenic regulators during the pathological development of intervertebral disc degeneration (IDD). However, effective treatment options for IDD are limited. Suramin is used to treat African sleeping sickness. This study aimed to investigate the pharmacological effects of suramin on mitigating IDD and to characterize the underlying mechanism.

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

Aims

Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.

Aims

The aim of the study was to compare two methods of calculating pelvic incidence (PI) and pelvic tilt (PT), either by using the femoral heads or acetabular domes to determine the bicoxofemoral axis, in patients with unilateral or bilateral primary hip osteoarthritis (OA).

Aims

Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology.

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

Aims

Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA.

Aims

Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA).

Aims

Modular dual-mobility constructs reduce the risk of dislocation after revision total hip arthroplasty (THA). However, questions about metal ions from the cobalt-chromium (CoCr) liner persist, and are particularly germane to patients being revised for adverse local tissue reactions (ALTR) to metal. We determined the early- to mid-term serum Co and Cr levels after modular dual-mobility components were used in revision and complex primary THAs, and specifically included patients revised for ALTR.

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Aims

The aims of this study were to describe the prevalence of previous lumbar surgery in patients who undergo total hip arthroplasty (THA) and to investigate their patient-reported outcomes (PROMs) one year post-operatively.

Aims

Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years.

Aims

Accurate placement of the acetabular component is essential in total hip arthroplasty (THA). The purpose of this study was to determine if the ability to achieve inclination of the acetabular component within the ‘safe-zone’ of 30° to 50° could be improved with the use of an inclinometer.

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.

Objectives

Sagittal alignment of the lumbosacral spine, and specifically pelvic incidence (PI), has been implicated in the development of spine pathology, but generally ignored with regards to diseases of the hip. We aimed to determine if increased PI is correlated with higher rates of hip osteoarthritis (HOA). The effect of PI on the development of knee osteoarthritis (KOA) was used as a negative control.

Aims

Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated.

Aims

There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication.

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment.

Cite this article: Bone Joint J 2017;99-B(1 Supple A):46–9.

The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.

Cite this article: Bone Joint J 2015;97-B:1017–23.

In this study we used subject-specific finite element analysis to investigate the mechanical effects of rotational acetabular osteotomy (RAO) on the hip joint and analysed the correlation between various radiological measurements and mechanical stress in the hip joint.

We evaluated 13 hips in 12 patients (two men and ten women, mean age at surgery 32.0 years; 19 to 46) with developmental dysplasia of the hip (DDH) who were treated by RAO.

Subject-specific finite element models were constructed from CT data. The centre–edge (CE) angle, acetabular head index (AHI), acetabular angle and acetabular roof angle (ARA) were measured on anteroposterior pelvic radiographs taken before and after RAO. The relationship between equivalent stress in the hip joint and radiological measurements was analysed.

The equivalent stress in the acetabulum decreased from 4.1 MPa (2.7 to 6.5) pre-operatively to 2.8 MPa (1.8 to 3.6) post-operatively (p < 0.01). There was a moderate correlation between equivalent stress in the acetabulum and the radiological measurements: CE angle (R = –0.645, p < 0.01); AHI (R = –0.603, p < 0.01); acetabular angle (R = 0.484, p = 0.02); and ARA (R = 0.572, p < 0.01).

The equivalent stress in the acetabulum of patients with DDH decreased after RAO. Correction of the CE angle, AHI and ARA was considered to be important in reducing the mechanical stress in the hip joint.

Cite this article: Bone Joint J 2015;97-B:492–7.

Objectives

The spinopelvic relationship (including pelvic incidence) has been shown to influence pelvic orientation, but its potential association with femoroacetabular impingement has not been thoroughly explored. The purpose of this study was to prove the hypothesis that decreasing pelvic incidence is associated with increased risk of cam morphology.

Peri-prosthetic bone loss caused by stress shielding may be associated with aseptic loosening of femoral components. In order to increase primary stability and to reduce stress shielding, a three-dimensional, cementless individual femoral (Evolution K) component was manufactured using pre-operative CT scans. Using dual energy x-ray absorptiometry, peri-prosthetic bone density was measured in 43 patients, three months, six months, 3.6 and 4.6 years after surgery. At final follow-up there was a significant reduction in mean bone density in the proximal Gruen zones of −30.3% (zone 7) and −22.8% (zone 1). The density in the other zones declined by a mean of between −4% and −16%. We conclude that the manufacture of a three-dimensional, custom-made femoral component could not prevent a reduction in peri-prosthetic bone density.

Degenerative problems of the hip in patients with childhood and adult onset neuromuscular disorders can be challenging to treat. Many orthopaedic surgeons are reluctant to recommend total hip replacement (THR) for patients with underlying neuromuscular disorders due to the perceived increased risks of dislocation, implant loosening, and lack of information about the functional outcomes and potential benefits of these procedures in these patients. Modular femoral components and alternative bearings which facilitate the use of large femoral heads, constrained acetabular components and perhaps more importantly, a better understanding about the complications and outcomes of THR in the patient with neuromuscular disorders, make this option viable. This paper will review the current literature and our experience with THR in the more frequently encountered neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):27–31.

Several radiological methods of measuring anteversion of the acetabular component after total hip replacement (THR) have been described. These studies used different definitions and reference planes to compare methods, allowing for misinterpretation of the results. We compared the reliability and accuracy of five current methods using plain radiographs (those of Lewinnek, Widmer, Liaw, Pradhan, and Woo and Morrey) with CT measurements, using the same definition and reference plane. We retrospectively studied the plain radiographs and CT scans in 84 hips of 84 patients who underwent primary THR. Intra- and inter-observer reliability were high for the measurement of inclination and anteversion with all methods on plain radiographs and CT scans. The measurements of inclination on plain radiographs were similar to the measurements using CT (p = 0.043). The mean difference between CT measurements was 0.6° (-5.9° to 6.8°).

Measurements using Widmer’s method were the most similar to those using CT (p = 0.088), with a mean difference between CT measurements of -0.9° (-10.4° to 9.1°), whereas the other four methods differed significantly from those using CT (p < 0.001).

This study has shown that Widmer’s method is the best for evaluating the anteversion of the acetabular component on plain radiographs.

Cite this article: Bone Joint J 2014; 96-B:597–603.

Patients with acetabular dysplasia commonly undergo peri-acetabular osteotomy after skeletal maturity to reduce the risk of the late development of osteoarthritis. Several studies have suggested that deformity of the femoral head influences the long-term outcome. We radiologically examined 224 hips in 112 patients with acetabular dysplasia and early-stage osteoarthritis. There were 103 women and nine men with a mean age of 37.6 years (18 to 49). A total of 201 hips were placed in the acetabular dysplasia group and 23 in a normal group. The centre–edge angle and acetabular head index were significantly smaller (both p < 0.001), and the acetabular angle, acetabular roof angle and roundness index were significantly greater in the acetabular dysplasia group than those in the normal group (all p < 0.001). There were significant correlations between the roundness index and other parameters. Femoral head shape may be influenced by the severity of the acetabular dysplasia.

Cite this article: Bone Joint J 2013;95-B:1192–6.

Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in three hips. Mean follow up was five years (two to 15). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in seven (39%) hips, in one case resulting in joint ankylosis. No hips dislocated.

Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function.

A variety of radiological methods of measuring version of the acetabular component after total hip replacement (THR) have been described. The aim of this study was to evaluate the reliability and validity of six methods (those of Lewinnek; Widmer; Hassan et al; Ackland, Bourne and Uhthoff; Liaw et al; and Woo and Morrey) that are currently in use. In 36 consecutive patients who underwent THR, version of the acetabular component was measured by three independent examiners on plain radiographs using these six methods and compared with measurements using CT scans. The intra- and interobserver reliabilities of each measurement were estimated. All measurements on both radiographs and CT scans had excellent intra- and interobserver reliability and the results from each of the six methods correlated well with the CT measurements. However, measurements made using the methods of Widmer and of Ackland, Bourne and Uhthoff were significantly different from the CT measurements (both p < 0.001), whereas measurements made using the remaining four methods were similar to the CT measurements. With regard to reliability and convergent validity, we recommend the use of the methods described by Lewinnek, Hassan et al, Liaw et al and Woo and Morrey for measurement of version of the acetabular component.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS).

Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results.

Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage.

The angle of inclination of the acetabular component in total hip replacement is a recognised contributing factor in dislocation and early wear. During non-navigated surgery, insertion of the acetabular component has traditionally been performed at an angle of 45° relative to the sagittal plane as judged by the surgeon’s eye, the operative inclination. Typically, the method used to assess inclination is the measurement made on the postoperative anteroposterior radiograph, the radiological inclination.

The aim of this study was to measure the intra-operative angle of inclination of the acetabular component on 60 consecutive patients in the lateral decubitus position when using a posterior approach during total hip replacement. This was achieved by taking intra-operative photographs of the acetabular inserter, representing the acetabular axis, and a horizontal reference. The results were compared with the post-operative radiological inclination.

The mean post-operative radiological inclination was 13° greater than the photographed operative inclination, which was unexpectedly high. It appears that in the lateral decubitus position with a posterior approach, the uppermost hemipelvis adducts, thus reducing the apparent operative inclination. Surgeons using the posterior approach in lateral decubitus need to aim for a lower operative inclination than when operating with the patient supine in order to achieve an acceptable radiological inclination.

We examined the morphology of mammalian hips asking whether evolution can explain the morphology of impingement in human hips. We describe two stereotypical mammalian hips, coxa recta and coxa rotunda. Coxa recta is characterised by a straight or aspherical section on the femoral head or head-neck junction. It is a sturdy hip seen mostly in runners and jumpers. Coxa rotunda has a round femoral head with ample head-neck offset, and is seen mostly in climbers and swimmers.

Hominid evolution offers an explanation for the variants in hip morphology associated with impingement. The evolutionary conflict between upright gait and the birth of a large-brained fetus is expressed in the female pelvis and hip, and can explain pincer impingement in a coxa profunda. In the male hip, evolution can explain cam impingement in coxa recta as an adaptation for running.

The ideal acetabular component is characterised by reliable, long-term fixation with physiological loading of bone and a low rate of wear. Trabecular metal is a porous construct of tantalum which promotes bony ingrowth, has a modulus of elasticity similar to that of cancellous bone, and should be an excellent material for fixation.

Between 2004 and 2006, 55 patients were randomised to receive either a cemented polyethylene or a monobloc trabecular metal acetabular component with a polyethylene articular surface. We measured the peri-prosthetic bone density around the acetabular components for up to two years using dual-energy x-ray absorptiometry.

We found evidence that the cemented acetabular component loaded the acetabular bone centromedially whereas the trabecular metal monobloc loaded the lateral rim and behaved like a hemispherical rigid metal component with regard to loading of the acetabular bone. We suspect that this was due to the peripheral titanium rim used for the mechanism of insertion.

We present the 10- to 17-year results of 112 computer-assisted design computer-assisted manufacture femoral components. The total hip replacements were performed between 1992 and 1998 in 111 patients, comprising 53 men and 58 women. Their mean age was 46.2 years (24.6 to 62.2) with a mean follow-up of 13 years (10 to 17). The mean Harris Hip Score improved from 42.4 (7 to 99) to 90.3 (38 to 100), the mean Oxford Hip Score from 43.1 (12 to 59) to 18.2 (12 to 51) and the mean Western Ontario MacMasters University Osteoarthritis Index score from 57.0 (7 to 96) to 11.9 (0 to 85). There was one revision due to failure of the acetabular component but no failures of the femoral component. There were no revisions for aseptic loosening. The worst-case survival in this cohort of custom femoral components at 13.2 years follow-up was 98.2% (95% confidence interval 95 to 99). Overall survival of this series of total hip replacements was 97.3% (95% confidence interval 95 to 99).

These results are comparable with the best medium- to long-term results for femoral components used in primary total hip replacement with any means of fixation.

We analysed which pre-operative factors could be used to predict the length of in-patient stay following unilateral primary total hip replacement undertaken for osteoarthritis. Data were collected prospectively from 2302 patients undergoing primary total hip replacement over a nine-year period. The relationships between the various pre-operative factors and length of stay were studied separately using either Student’s t-test or Pearson’s correlation, and then subjected to multiple linear regression analysis.

The mean length of stay was 8.1 days (median 7; 3 to 58). After adjusting for the effects of other pre-operative factors, younger age, male gender, higher combined Harris hip function and activity score, higher general health perception dimension of the Short-Form 36 score, and non-steroidal anti-inflammatory drug use were all found to be significantly associated with a reduced length of stay.

Transient osteoporosis of the hip is a disorder characterised by pain, and associated with temporary osteopaenia. Although osteopaenia is the essence of the condition, data do not exist about the local bone density of the femoral neck if no medication is administered. We describe three patients who were treated with limitation of weight-bearing only. Repeated bone mineral density measurements were obtained, and that at the femoral neck was lowest two months after the onset of the condition. The mean reduction in bone mineral density when compared with an age-matched control group was 13% (3% to 24%). Spontaneous recovery was observed in all patients.

We investigated 219 revisions of total hip replacement (THR) in 211 patients using a collarless double-taper cemented femoral component. The mean age of the patients was 72 years (30 to 90). The 137 long and 82 standard length stems were analysed separately. The mean follow-up was six years (2 to 18), and no patient was lost to follow-up.

Survival of the long stems to re-revision for aseptic loosening at nine years was 98% (95% confidence interval (CI) 94 to 100), and for the standard stems was 93% (95% CI 85 to 100). At five years, one long stem was definitely loose radiologically and one standard stem was probably loose. Pre-operative femoral bone deficiency did not influence the results for the long stems, and corrective femoral osteotomy was avoided, as were significant subsidence, major stress shielding and persistent thigh pain.

Because of these reliable results, cemented long collarless double-taper femoral components are recommended for routine revision THR in older patients.