Objectives. The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?. Methods. We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. Results. We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. Conclusions. Further observational research should be conducted to define the population of interest before future interventional studies are performed. Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Aims

Radiostereometric analysis (RSA) is the most accurate radiological method to measure in vivo wear of highly cross-linked polyethylene (XLPE) acetabular components. We have previously reported very low wear rates for a sequentially irradiated and annealed X3 XLPE liner (Stryker Orthopaedics, USA) when used in conjunction with a 32 mm femoral heads at ten-year follow-up. Only two studies have reported the long-term wear rate of X3 liners used in conjunction with larger heads using plain radiographs which have poor sensitivity. The aim of this study was to measure the ten-year wear of thin X3 XLPE liners against larger 36 or 40 mm articulations with RSA.

Aims

To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia.

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Aims

The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

Aims

This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year.

Aims

This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time.

Aims

The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients.

Aims

The main aims were to identify risk factors predictive of a radiolucent line (RLL) around the acetabular component with an interface bioactive bone cement (IBBC) technique in the first year after THA, and evaluate whether these risk factors influence the development of RLLs at five and ten years after THA.

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

Aims

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

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.

Aims

To analyse the effectiveness of debridement and implant retention (DAIR) in patients with hip periprosthetic joint infection (PJI) and the relationship to patient characteristics. The outcome was evaluated in hips with confirmed PJI and a follow-up of not less than two years.

Aims

The increased in vivo resistance to wear of highly crosslinked polyethylene (HXLPE) in total hip arthroplasty (THA) has led to an increased use of larger articulations which have been shown to reduce the incidence of early dislocation. To date, there are few reports of the wear of larger articulations using second generation HXLPE liners. Our prospective cohort study measured the bedding-in and early wear of large (36 mm and 40 mm diameter) articulations involving a second generation X3 HXLPE liner and compared our findings with previous clinical and in vitro studies of the same material.

In this in vitro study of the hip joint we examined which soft tissues act as primary and secondary passive rotational restraints when the hip joint is functionally loaded. A total of nine cadaveric left hips were mounted in a testing rig that allowed the application of forces, torques and rotations in all six degrees of freedom. The hip was rotated throughout a complete range of movement (ROM) and the contributions of the iliofemoral (medial and lateral arms), pubofemoral and ischiofemoral ligaments and the ligamentum teres to rotational restraint was determined by resecting a ligament and measuring the reduced torque required to achieve the same angular position as before resection. The contribution from the acetabular labrum was also measured. Each of the capsular ligaments acted as the primary hip rotation restraint somewhere within the complete ROM, and the ligamentum teres acted as a secondary restraint in high flexion, adduction and external rotation. The iliofemoral lateral arm and the ischiofemoral ligaments were primary restraints in two-thirds of the positions tested. Appreciation of the importance of these structures in preventing excessive hip rotation and subsequent impingement/instability may be relevant for surgeons undertaking both hip joint preserving surgery and hip arthroplasty.

Cite this article: Bone Joint J 2015; 97-B:484–91.

Pelvic discontinuity represents a rare but challenging problem for orthopaedic surgeons. It is most commonly encountered during revision total hip replacement, but can also result from an iatrogentic acetabular fracture during hip replacement. The general principles in management of pelvic discontinuity include restoration of the continuity between the ilium and the ischium, typically with some form of plating. Bone grafting is frequently required to restore pelvic bone stock. The acetabular component is then impacted, typically using an uncemented, trabecular metal component. Fixation with multiple supplemental screws is performed. For larger defects, a so-called ‘cup–cage’ reconstruction, or a custom triflange implant may be required. Pre-operative CT scanning can greatly assist in planning and evaluating the remaining bone stock available for bony ingrowth. Generally, good results have been reported for constructs that restore stability to the pelvis and allow some form of biologic ingrowth.

Cite this article: Bone Joint J 2013;95-B, Supple A:109–13.

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

This conversation represents an attempt by several arthroplasty surgeons to critique several abstracts presented over the last year as well as to use them as a jumping off point for trying to figure out where they fit in into our current understanding of multiple issues in modern hip and knee arthroplasty.

Objectives

The number of surgical procedures performed each year to treat femoroacetabular impingement (FAI) continues to rise. Although there is evidence that surgery can improve symptoms in the short-term, there is no evidence that it slows the development of osteoarthritis (OA). We performed a feasibility study to determine whether patient and surgeon opinion was permissive for a Randomised Controlled Trial (RCT) comparing operative with non-operative treatment for FAI.

In this prospective study a total of 80 consecutive Chinese patients with Crowe type I or II developmental dysplasia of the hip were randomly assigned for hip resurfacing arthroplasty (HRA) or total hip replacement (THR).

Three patients assigned to HRA were converted to THR, and three HRA patients and two THR patients were lost to follow-up. This left a total of 34 patients (37 hips) who underwent HRA and 38 (39 hips) who underwent THR. The mean follow-up was 59.4 months (52 to 70) in the HRA group and 60.6 months (50 to 72) in the THR group. There was no failure of the prosthesis in either group. Flexion of the hip was significantly better after HRA, but there was no difference in the mean post-operative Harris hip scores between the groups. The mean size of the acetabular component in the HRA group was significantly larger than in the THR group (49.5 mm vs 46.1 mm, p = 0.001). There was no difference in the mean abduction angle of the acetabular component between the two groups.

Although the patients in this series had risk factors for failure after HRA, such as low body weight, small femoral heads and dysplasia, the clinical results of resurfacing in those with Crowe type I or II hip dysplasia were satisfactory. Patients in the HRA group had a better range of movement, although neck-cup impingement was observed. However, more acetabular bone was sacrificed in HRA patients, and it is unclear whether this will have an adverse effect in the long term.

Between November 1997 and December 2000 we performed 27 total hip replacements in 22 patients with high congenital dislocation of the hip using porous tantalum monoblock acetabular components implanted in the true acetabular bed. Clinical and radiological evaluation was performed at regular intervals for a mean of 10.2 years (8.5 to 12). The mean Harris Hip Score improved from 48.3 (15 to 65) pre-operatively to 89.5 (56 to 100) at the final follow-up. The mean Oxford Hip Score was 49.5 (35 to 59) pre-operatively and decreased to 21.2 (12 to 48) at one year and 15.2 (10 to 28) at final follow-up. Migration of the acetabular component was assessed with the EBRA software system. There was a mean migration of 0.68 mm (0.49 to 0.8) in the first year and a mean 0.89 mm (0.6 to 0.98) in the second year, after excluding one initial excessive migration. No revision was necessary for any reason, no acetabular component became loose, and no radiolucent lines were observed at the final follow-up.

The porous tantalum monoblock acetabular component is an implant offering adequate initial stability in conjunction with a modulus of elasticity and porosity close to that of cancellous bone. It favours bone ingrowth, leading to good mid-term results.

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique.

At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Metal-on-metal bearings for total hip replacement (THR) are becoming increasingly popular. Improved wear characteristics mean that these articulations are being inserted into younger patients in the form of THR and resurfacing procedures. This has led to concerns regarding potential carcinogenicity because of the increased exposure to metal ions that the procedure brings.

We have studied the serum cobalt and chromium concentrations in patients who had primary, well-fixed Ring metal-on-metal THRs for more than 30 years. The levels of cobalt and chromium were elevated by five and three times, respectively compared with those in our reference groups. Metal-on-metal articulations appear to be the source of metal ions throughout the life of the prosthesis. In three patients who had undergone revision of a previous metal-on-metal THR to a metal-on-polyethylene replacement the levels of metal ions were within the normal range. The elevations of cobalt and chromium ions seen in our study were comparable with those in patients with modern metal-on-metal THRs.

Immunosuppression following intra-articular injections of steroid into the hip may interfere with asepsis in a subsequent total hip arthroplasty (THA). We have undertaken a retrospective, matched, cohort study of infective complications after THA, in 40 patients who had received such an injection and 40 who had not.

In the injection group there were five revisions, four of which were for deep infection. There were none in the matched group. The overall rate of revision in our database of 979 primary THAs was 1.02%. Six additional patients who had received injections underwent investigation for infection because of persistent problems in the hip as compared with one in the control group.

A reduced femoral offset in total hip replacement has been thought to be disadvantageous. We reviewed the results of 54 consecutive primary total hip replacements in 49 patients (mean age of 68 years) performed between August 1990 and December 1994, with a mean follow-up of 8.8 years (sd 2.1). The mean pre-operative femoral offset for these hips was 41 mm (sd 7.4). All patients received a low-offset Charnley stem and a polyethylene cup inserted by a single surgeon.

At their latest follow-up, surviving patients had a significant improvement in the performance of their hip. Three had undergone revision, one each for deep infection, recurrent dislocation and late pain with subluxation. No hips had been revised, or were at risk of revision, for aseptic loosening. The mean annual linear rate of wear was 0.2 mm (sd 0.08) for the whole group. There was no correlation between the pre-operative femoral offset and the post-operative rate of wear. Our survivorship estimate was 91% when revision for any reason was taken as an end-point, but 100% if aseptic loosening was considered as the end-point. Our study demonstrates that a low-offset femoral stem can produce good, medium-term results.