Aims. Metal-on-metal hip resurfacing (MoM-HR) has seen decreased usage due to safety and longevity concerns. Joint registries have highlighted the risks in females, smaller hips, and hip dysplasia. This study aimed to identify if reported risk factors are linked to revision in a long-term follow-up of MoM-HR performed by a non-designer surgeon. Methods. A retrospective review of consecutive MoM hip arthroplasties (MoM-HRAs) using Birmingham Hip Resurfacing was conducted. Data on procedure side, indication, implant sizes and orientation, highest blood cobalt and chromium ion concentrations, and all-cause revision were collected from local and UK National Joint Registry records. Results. A total of 243 hips (205 patients (163 male, 80 female; mean age at surgery 55.3 years (range 25.7 to 75.3)) with MoM-HRA performed between April 2003 and October 2020 were included. Mean follow-up was 11.2 years (range 0.3 to 17.8). Osteoarthritis was the most common indication (93.8%), and 13 hips (5.3%; 7M:6F) showed dysplasia (lateral centre-edge angle < 25°). Acetabular cups were implanted at a median of 45.4° abduction (interquartile range 41.9° - 48.3°) and stems neutral or valgus to the native neck-shaft angle. In all, 11 hips (4.5%; one male, ten females) in ten patients underwent revision surgery at a mean of 7.4 years (range 2.8 to 14.2), giving a cumulative survival rate of 94.8% (95% confidence interval (CI) 91.6% to 98.0%) at ten years, and 93.4% (95% CI 89.3% to 97.6%) at 17 years. For aseptic revision, male survivorship was 100% at 17 years, and 89.6% (95% CI 83.1% to 96.7%) at ten and 17 years for females. Increased metal ion levels were implicated in 50% of female revisions, with the remaining being revised for unexplained pain or avascular necrosis. Conclusion. The Birmingham MoM-HR showed 100% survivorship in males, exceeding the National Institute for Health and Care Excellence ‘5% at ten years’ threshold. Female sex and small component sizes are independent risk factors. Dysplasia alone is not a contraindication to resurfacing. Cite this article: Bone Jt Open 2023;4(11):853–858

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

Aims. The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union. Methods. We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union. Results. A total of 331 patients underwent PAO during the study period with 56 (15.4%) stress fractures: 46 fractures of the retroacetabular posterior column, five cases of ischiopubic stress fracture, and five cases of concurrent ischiopubic and retroacetabular stress fractures. Overall, 86% (48/56) healed without intervention. Univariate analysis revealed that stress fractures occurred more frequently in females (p = 0.040), older patients (mean age 27.6 years (SD 8.4) vs 23.8 (SD 9.0); p = 0.003), and most often with the use of the broad Mast chisel (28.5%; p < 0.001). Multivariable analysis revealed that increasing age (odds ratio (OR) 1.04; 95% CI 1.01 to 1.07; p = 0.028) and use of the broad Mast chisel (OR 5.1 (95% CI 1.3 to 19.0) compared to narrow Ganz chisel; p = 0.038) and surgeon (p = 0.043) were associated with increased risk of stress fracture. Patients with stress fractures were less likely to have healed osteotomies after one-year follow-up (76% vs 96%; p < 0.001). Conclusion. Stress fracture of the posterior column may be an under-recognized complication following PAO, and the rate may be influenced by surgical technique. Consideration should be given to using a narrow chisel during the ischial cut to reduce the risk of stress propagation through the posterior column. Cite this article: Bone Joint J 2022;104-B(9):1017–1024

Aims. Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. Methods. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Results. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. Conclusion. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two ‘at risk’ alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making. Cite this article: Bone Jt Open 2023;4(3):182–187

Aims. This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. Methods. This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. Results. The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). Conclusion. LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate. Cite this article: Bone Jt Open 2024;5(2):123–131

Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion. SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691

Aims. Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA). Methods. We analyzed 151,096 primary cementless THAs from the German Arthroplasty Registry (EPRD) between November 2012 and November 2020. Cumulative incidence of revision for mechanical complications for standard and four modified PE liners (lipped, offset, angulated/offset, and angulated) was determined using competing risk analysis at one and seven years. Confounders were investigated with a Cox proportional-hazards model. Results. Median follow-up was 868 days (interquartile range 418 to 1,364). The offset liner design reduced the risk of revision (hazard ratio (HR) 0.68 (95% confidence interval (CI) 0.50 to 0.92)), while the angulated/offset liner increased the risk of revision for mechanical failure (HR 1.81 (95% CI 1.38 to 2.36)). The cumulative incidence of revision was lowest for the offset liner at one and seven years (1.0% (95% CI 0.7 to 1.3) and 1.8% (95% CI 1.0 to 3.0)). No difference was found between standard, lipped, and angulated liner designs. Higher age at index primary THA and an Elixhauser Comorbidity Index greater than 0 increased the revision risk in the first year after surgery. Implantation of a higher proportion of a single design of liner in a hospital reduced revision risk slightly but significantly (p = 0.001). Conclusion. The use of standard acetabular component liners remains a good choice in primary uncemented THA, as most modified liner designs were not associated with a reduced risk of revision for mechanical failure. Offset liner designs were found to be beneficial and angulated/offset liner designs were associated with higher risks of revision. Cite this article: Bone Joint J 2022;104-B(7):801–810

Aims. Periprosthetic femoral fractures (PPF) are a serious complication of total hip arthroplasty (THA) and are becoming an increasingly common indication for revision arthroplasty with the ageing population. This study aimed to identify potential risk factors for PPF based on an analysis of registry data. Methods. Cases recorded with PPF as the primary indication for revision arthroplasty in the German Arthroplasty Registry (Endoprothesenregister Deutschland (EPRD)), as well as those classified as having a PPF according to the International Classification of Diseases (ICD) codes in patients’ insurance records were identified from the complete datasets of 249,639 registered primary hip arthroplasties in the EPRD and included in the analysis. Results. The incidence of PPFs was higher (24.6%; 1,483) than reported in EPRD annual reports listing PPF as the main reason for revision (10.9%; 654). The majority of fractures occurred intraoperatively and were directly related to the implantation process. Patients who were elderly, female, or had comorbidities were at higher risk of PPFs (p < 0.001). German hospitals with a surgical volume of < 300 primary procedures per year had a higher rate of PPFs (p < 0.001). The use of cemented and collared prostheses had a lower fracture risk PPF compared to uncemented and collarless components, respectively (both p < 0.001). Collared prostheses reduced the risk of PPF irrespective of the fixation method and hospital’s surgical volume. Conclusion. The high proportion of intraoperative fractures emphasises the need to improve surgeon training and surgical technique. Registry data should be interpreted with caution because of potential differences in coding standards between institutions. Cite this article: Bone Joint J 2021;103-B(4):650–658

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. Methods. Retrospective analysis was performed of a multicentre THA database of 9,414 patients with preoperative imaging (dynamic spinopelvic radiographs and pelvic CT scans). Several spinopelvic parameter measurements were made by engineers using advanced software including sacral slope (SS), standing anterior pelvic plane tilt (APPT), spinopelvic tilt (SPT), lumbar lordosis (LL), and PI. Lumbar flexion (LF) was determined by change in LL between standing and flexed-seated lateral radiographs. Abnormal pelvic mobility was defined as ∆SPT ≥ 20° between standing and flexed-forward positions. Sagittal spinal deformity (SSD) was defined as PI-LL mismatch > 10°. Results. PI showed a positive correlation with parameters of SS, SPT, and LL (r-value range 0.468 to 0.661). Patients with a higher PI value showed higher degrees of standing LL, likely as a compensatory measure to maintain sagittal spine balance. There was a positive correlation between LL and LF such that patients with less standing LL had decreased LF (r = 0.49). Similarly, there was a positive correlation between increased SSD and decreased LF (r = 0.54). PI in isolation did not show any significant correlation with lumbar (r = 0.04) or pelvic mobility (r = 0.02). The majority of patients (range 89.4% to 94.2%) had normal lumbar and pelvic mobility regardless of the PI value. Conclusion. The PI value alone is not indicative of either spinal or pelvic mobility, and thus in isolation may not be a risk factor for THA instability. Patients with SSD had higher rates of spinopelvic stiffness, which may be the mechanism by which PI relates to THA instability risk, but further clinical studies are required. Cite this article: Bone Joint J 2022;104-B(3):352–358

Aims. Joint registries typically use revision of an implant as an endpoint and report survival rates after a defined number of years. However, reporting lifetime risk of revision may be more meaningful, especially in younger patients. We aimed to assess lifetime risk of revision for patients in defined age groups at the time of primary surgery. Methods. The New Zealand Joint Registry (NZJR) was used to obtain rates and causes of revision for all primary total hip arthroplasties (THAs) performed between January 1999 and December 2016. The NZJR is linked to the New Zealand Registry of Births, Deaths and Marriages to obtain complete and accurate data. Patients were stratified by age at primary surgery, and lifetime risk of revision calculated according to age, sex, and American Society of Anesthesiologists (ASA) classification. The most common causes for revision were also analyzed for each age group. Results. The overall, ten-year implant survival rate was 93.6% (95% confidence interval (CI) 93.4% to 93.8%). It was lowest in the youngest age group (46 to 50 years), rising sequentially with increasing age to 97.5% in the oldest group (90 to 95 years). Lifetime risk of revision surgery was 27.6% (95% CI 27.3% to 27.8%) in those aged 46 to 50 years, decreasing with age to 1.1% (95% CI 0.0% to 5.8%) in those aged 90 to 95 years at the time of primary surgery. Higher ASA grades were associated with an increased lifetime risk of revision across all ages. The commonest causes for revision THA were aseptic loosening, infection, periprosthetic fracture, and dislocation. Conclusion. When counselling patients preoperatively, the lifetime risk of revision may be a more meaningful and useful measure of longer-term outcome than implant survival at defined time periods. This study highlights the considerably increased likelihood of subsequent revision surgery in younger age groups. Cite this article: Bone Joint J 2021;103-B(3):479–485

Aims. The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days. Methods. We obtained individual-based information on SES markers (cohabitation, education, income, and savings) on 103,901 THA patients from Danish health registries between 1 January 1995 and 31 December 2017. The primary outcome measure was any hospital-treated infection (i.e. all infections). The secondary outcomes were further specified to specific hospital-treated infections (pneumonia, urinary tract infection, and periprosthetic joint infection). The primary timepoint was within 90 days. In addition, the outcomes were further evaluated within 30 days. We calculated the cumulative incidence, and used the pseudo-observation method and generalized linear regression to estimate adjusted risk ratios (RRs) with 95% confidence intervals (CIs) for each marker. Results. The cumulative incidence of any infection at 90 days was highest in patients who lived alone (1.5% (95% CI 1.3 to 1.6)) versus cohabitant (0.7% (95% CI 0.7 to 0.8)), had the lowest educational achievement (1.1% (95% CI 1.0 to 1.2)) versus highest (0.7% (95% CI 0.5 to 0.8)), had the lowest income (1.6% (95% CI 1.5 to 1.70)) versus highest (0.4% (95% CI 0.3 to 0.5)), or had lowest savings (1.3% (95% CI 1.2 to 1.4)) versus highest (0.7% (95% CI 0.6 to 0.8)). Within 90 days, the RRs for any infection were 1.3 (95% CI 1.2 to 1.4) for patients living alone versus cohabiting, 1.2 (95% CI 1.0 to 1.3) for low education achievement versus high, 1.7 (95% CI 1.4 to 2.1) for low income versus high income, and 1.5 (95% CI 1.4 to 1.8) for low savings versus high savings. The same trends were also seen for any infections within the first 30 days. Conclusion. Our study provides evidence that socioeconomic inequality adversely influences the risk of infection after THA, thus contributing to healthcare disparities and inequalities. We found that living alone, low educational achievement, low income, or low savings were associated with higher risks of infections within the first 30 and 90 days after THA. Therefore, the development of targeted intervention strategies with the aim of increasing awareness of patients identified as being at greatest risk is needed to mitigate the impact of SES on the risk of infections following THA. Cite this article: Bone Joint J 2022;104-B(2):221–226

Aims. To determine if primary cemented acetabular component geometry (long posterior wall (LPW), hooded, or offset reorientating) influences the risk of revision total hip arthroplasty (THA) for instability or loosening. Methods. The National Joint Registry (NJR) dataset was analyzed for primary THAs performed between 2003 and 2017. A cohort of 224,874 cemented acetabular components were included. The effect of acetabular component geometry on the risk of revision for instability or for loosening was investigated using log-binomial regression adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, operating surgeon grade, surgical approach, polyethylene crosslinking, and prosthetic head size. A competing risk survival analysis was performed with the competing risks being revision for other indications or death. Results. The distribution of acetabular component geometries was: LPW 81.2%; hooded 18.7%; and offset reorientating 0.1%. There were 3,313 (1.5%) revision THAs performed, of which 815 (0.4%) were for instability and 838 (0.4%) were for loosening. Compared to the LPW group, the adjusted subhazard ratio of revision for instability in the hooded group was 2.31 (p < 0.001) and 4.12 (p = 0.047) in the offset reorientating group. Likewise, the subhazard ratio of revision for loosening was 2.65 (p < 0.001) in the hooded group and 13.61 (p < 0.001) in the offset reorientating group. A time-varying subhazard ratio of revision for instability (hooded vs LPW) was found, being greatest within the first three months. Conclusion. This registry-based study confirms a significantly higher risk of revision after cemented THA for instability and for loosening when a hooded or offset reorientating acetabular component is used, compared to a LPW component. Further research is required to clarify if certain patients benefit from the use of hooded or offset reorientating components, but we recommend caution when using such components in routine clinical practice. Cite this article: Bone Joint J 2021;103-B(11):1669–1677

Aims. The aim of this study was to determine if uncemented acetabular polyethylene (PE) liner geometry, and lip size, influenced the risk of revision for instability or loosening. Methods. A total of 202,511 primary total hip arthroplasties (THAs) with uncemented acetabular components were identified from the National Joint Registry (NJR) dataset between 2003 and 2017. The effect of liner geometry on the risk of revision for instability or loosening was investigated using competing risk regression analyses adjusting for age, sex, American Society of Anesthesiologists grade, indication, side, institution type, surgeon grade, surgical approach, head size, and polyethylene crosslinking. Stratified analyses by surgical approach were performed, including pairwise comparisons of liner geometries. Results. The distribution of liner geometries were neutral (39.4%; 79,822), 10° (34.5%; 69,894), 15° (21.6%; 43,722), offset reorientating (2.8%; 5705), offset neutral (0.9%; 1,767), and 20° (0.8%; 1,601). There were 690 (0.34%) revisions for instability. Compared to neutral liners, the adjusted subhazard ratios of revision for instability were: 10°, 0.64 (p < 0.001); 15°, 0.48 (p < 0.001); and offset reorientating, 1.6 (p = 0.010). No association was found with other geometries. 10° and 15° liners had a time-dependent lower risk of revision for instability within the first 1.2 years. In posterior approaches, 10° and 15° liners had a lower risk of revision for instability, with no significant difference between them. The protective effect of lipped over neutral liners was not observed in laterally approached THAs. There were 604 (0.3%) revisions for loosening, but no association between liner geometry and revision for loosening was found. Conclusion. This registry-based study confirms a lower risk of revision for instability in posterior approach THAs with 10° or 15° lipped liners compared to neutral liners, but no significant difference between these lip sizes. A higher revision risk is seen with offset reorientating liners. The benefit of lipped geometries against revision for instability was not seen in laterally approached THAs. Liner geometry does not seem to influence the risk of revision for loosening. Cite this article: Bone Joint J 2021;103-B(12):1774–1782

Aims. A recent report from France suggested an association between the use of cobalt-chrome (CoCr) femoral heads in total hip arthroplasties (THAs) and an increased risk of dilated cardiomyopathy and heart failure. CoCr is a commonly used material in orthopaedic implants. If the reported association is causal, the consequences would be significant given the millions of joint arthroplasties and other orthopaedic procedures in which CoCr is used annually. We examined whether CoCr-containing THAs were associated with an increased risk of all-cause mortality, heart outcomes, cancer, and neurodegenerative disorders in a large national database. Methods. Data from the National Joint Registry was linked to NHS English hospital inpatient episodes for 374,359 primary THAs with up to 14.5 years' follow-up. We excluded any patients with bilateral THAs, knee arthroplasties, indications other than osteoarthritis, aged under 55 years, and diagnosis of one or more outcome of interest before THA. Implants were grouped as either containing CoCr or not containing CoCr. The association between implant construct and the risk of all-cause mortality and incident heart failure, cancer, and neurodegenerative disorders was examined. Results. There were 158,677 individuals (42.4%) with an implant containing CoCr. There were 47,963 deaths, 27,332 heart outcomes, 35,720 cancers, and 22,025 neurodegenerative disorders. There was no evidence of an association between patients with CoCr implants and higher rates of any of the outcomes. Conclusion. CoCr-containing THAs did not have an increased risk of all-cause mortality, or clinically meaningful heart outcomes, cancer, or neurodegenerative disorders into the second decade post-implantation. Our findings will help reassure clinicians and the increasing number of patients receiving primary THA worldwide that the use of CoCr-containing implants is not associated with significant adverse systemic effects. Cite this article: Bone Joint J 2022;104-B(3):359–367

Aims. Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA. Methods. We performed an observational study using National Joint Registry (NJR) data. We included adult patients who underwent primary THA for osteoarthritis, recorded in the NJR between 2003 and 2016. Exposures were operating surgeon grade (consultant or trainee) and whether or not trainees were directly supervised by a scrubbed consultant. Outcomes were all-cause revision and the indication for revision up to ten years. We used methods of survival analysis, adjusted for patient, operation, and healthcare setting factors. Results. We included 603,474 THAs, of which 58,137 (9.6%) procedures were performed by a trainee. There was no association between surgeon grade and all-cause revision up to ten years (crude hazard ratio (HR) 1.00 (95% confidence interval (CI) 0.94 to 1.07); p = 0.966), a finding which persisted with adjusted analysis. Fully adjusted analysis demonstrated an association between trainees operating without scrubbed consultant supervision and an increased risk of all-cause revision (HR 1.10 (95% CI 1.00 to 1.21); p = 0.045). There was an association between trainee-performed THA and revision for instability (HR 1.14 (95% CI 1.01 to 1.30); p = 0.039). However, this was not observed in adjusted models, or when trainees were supervised by a scrubbed consultant. Conclusion. Within the current training system in England and Wales, appropriately supervised trainees achieve comparable THA survival to consultants. Trainees who are supervised by a scrubbed consultant achieve superior outcomes compared to trainees who are not supervised by a scrubbed consultant, particularly in terms of revision for instability. Cite this article: Bone Joint J 2022;104-B(3):341–351

Aims. The aim of our study was to investigate the effect of asymmetric crosslinked polyethylene liner use on the risk of revision of cementless and hybrid total hip arthroplasties (THAs). Methods. We undertook a registry study combining the National Joint Registry dataset with polyethylene manufacturing characteristics as supplied by the manufacturers. The primary endpoint was revision for any reason. We performed further analyses on other reasons including instability, aseptic loosening, wear, and liner dissociation. The primary analytic approach was Cox proportional hazard regression. Results. A total of 213,146 THAs were included in the analysis. Overall, 2,997 revisions were recorded, 1,569 in THAs with a flat liner and 1,428 in THAs using an asymmetric liner. Flat liner THAs had a higher risk of revision for any reason than asymmetric liner THAs when implanted through a Hardinge/anterolateral approach (hazard ratio (HR) 1.169, 95% confidence interval (CI) 1.022 to 1.337) and through a posterior approach (HR 1.122, 95% CI 1.108 to 1.346). There was no increased risk of revision for aseptic loosening when asymmetric liners were used for any surgical approach. A separate analysis of the three most frequently used crosslinked polyethylene liners was in agreement with this finding. When analyzing THAs with flat liners only, THAs implanted through a Hardinge/anterolateral approach were associated with a reduced risk of revision for instability compared to posterior approach THAs (HR 0.561 (95% CI 0.446 to 0.706)). When analyzing THAs with an asymmetric liner, there was no significant difference in the risk of revision for instability between the two approaches (HR 0.838 (95% CI 0.633 to 1.110)). Conclusion. For THAs implanted through the posterior approach, the use of asymmetric liners reduces the risk of revision for instability and revision for any reason. In THAs implanted through a Hardinge/anterolateral approach, the use of an asymmetric liner was associated with a reduced risk of revision. The effect on revision for instability was less pronounced than in the posterior approach. Cite this article: Bone Joint J 2021;103-B(9):1479–1487

Aims. The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture. Methods. This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality. Results. The cohort consisted of 1,619 patients with a mean age of 82.2 years (50 to 104), of whom 1,100 (67.9%) were female. In total, 29 patients (1.8%) underwent a reoperation; 12 patients (0.7%) sustained a PFF during the observation period (United Classification System (UCS)-A n = 2; UCS-B n = 5; UCS-C n = 5), of whom ten underwent surgical management. Perioperative delirium was independently associated with the occurrence of PFF (hazard ratio (HR) 5.92; p = 0.013) and surgery for UCS-B PFF (HR 21.7; p = 0.022). Neither all-cause reoperation nor PFF-related surgery was independently associated with mortality (HR 0.66; p = 0.217 and HR 0.38; p = 0.170, respectively). Perioperative delirium, male sex, older age, higher ASA grade, and pre-fracture residential status were independently associated with increased mortality risk following hemiarthroplasty (p < 0.001). Conclusion. The cumulative incidence of PFF at four years was 1.1% in elderly patients following cemented PTS hemiarthroplasty for a hip fracture. Perioperative delirium was independently associated with a PFF. However, reoperation for PPF was not independently associated with patient mortality after adjusting for patient-specific factors. Cite this article: Bone Jt Open 2024;5(4):269–276

Aims. Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error. Methods. A total of 356 patients undergoing primary THA were prospectively enrolled from November 2016 to March 2018. Clinically relevant error using the CAS system was defined as a difference of > 5° between CAS and 3D radiological reconstruction measurements for acetabular component inclination and anteversion. Univariate and multiple logistic regression analyses were conducted to determine whether hypermobile (. Δ. sacral slope(SS). stand-sit. > 30°), or stiff (. ∆. SS. stand-sit. < 10°) spinopelvic mobility contributed to increased error rates. Results. The paired absolute difference between CAS and postoperative imaging measurements was 2.3° (standard deviation (SD) 2.6°) for inclination and 3.1° (SD 4.2°) for anteversion. Using a target zone of 40° (± 10°) (inclination) and 20° (± 10°) (anteversion), postoperative standing radiographs measured 96% of acetabular components within the target zone for both inclination and anteversion. Multiple logistic regression analysis controlling for BMI and sex revealed that hypermobile spinopelvic mobility significantly increased error rates for anteversion (odds ratio (OR) 2.48, p = 0.009) and inclination (OR 2.44, p = 0.016), whereas stiff spinopelvic mobility increased error rates for anteversion (OR 1.97, p = 0.028). There were no dislocations at a minimum three-year follow-up. Conclusion. Despite high reliability in acetabular positioning for inclination in a large patient cohort using an optical CAS system, hypermobile and stiff spinopelvic mobility significantly increased the risk of clinically relevant errors. In patients with abnormal spinopelvic mobility, CAS systems should be adjusted for use to avoid acetabular component misalignment and subsequent risk for long-term dislocation. Cite this article: Bone Jt Open 2022;3(6):475–484

Aims. Type 2 diabetes mellitus (T2DM) impairs bone strength and is a significant risk factor for hip fracture, yet currently there is no reliable tool to assess this risk. Most risk stratification methods rely on bone mineral density, which is not impaired by diabetes, rendering current tests ineffective. CT-based finite element analysis (CTFEA) calculates the mechanical response of bone to load and uses the yield strain, which is reduced in T2DM patients, to measure bone strength. The purpose of this feasibility study was to examine whether CTFEA could be used to assess the hip fracture risk for T2DM patients. Methods. A retrospective cohort study was undertaken using autonomous CTFEA performed on existing abdominal or pelvic CT data comparing two groups of T2DM patients: a study group of 27 patients who had sustained a hip fracture within the year following the CT scan and a control group of 24 patients who did not have a hip fracture within one year. The main outcome of the CTFEA is a novel measure of hip bone strength termed the Hip Strength Score (HSS). Results. The HSS was significantly lower in the study group (1.76 (SD 0.46)) than in the control group (2.31 (SD 0.74); p = 0.002). A multivariate model showed the odds of having a hip fracture were 17 times greater in patients who had an HSS ≤ 2.2. The CTFEA has a sensitivity of 89%, a specificity of 76%, and an area under the curve of 0.90. Conclusion. This preliminary study demonstrates the feasibility of using a CTFEA-based bone strength parameter to assess hip fracture risk in a population of T2DM patients. Cite this article: Bone Joint J 2021;103-B(9):1497–1504

Aims. The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. Methods. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. Results. A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. Conclusion. Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580–585

Aims. Pelvic tilt (PT) can significantly change the functional orientation of the acetabular component and may differ markedly between patients undergoing total hip arthroplasty (THA). Patients with stiff spines who have little change in PT are considered at high risk for instability following THA. Femoral component position also contributes to the limits of impingement-free range of motion (ROM), but has been less studied. Little is known about the impact of combined anteversion on risk of impingement with changing pelvic position. Methods. We used a virtual hip ROM (vROM) tool to investigate whether there is an ideal functional combined anteversion for reduced risk of hip impingement. We collected PT information from functional lateral radiographs (standing and sitting) and a supine CT scan, which was then input into the vROM tool. We developed a novel vROM scoring system, considering both seated flexion and standing extension manoeuvres, to quantify whether hips had limited ROM and then correlated the vROM score to component position. Results. The vast majority of THA planned with standing combined anteversion between 30° to 50° and sitting combined anteversion between 45° to 65° had a vROM score > 99%, while the majority of vROM scores less than 99% were outside of this zone. The range of PT in supine, standing, and sitting positions varied widely between patients. Patients who had little change in PT from standing to sitting positions had decreased hip vROM. Conclusion. It has been shown previously that an individual’s unique spinopelvic alignment influences functional cup anteversion. But functional combined anteversion, which also considers stem position, should be used to identify an ideal THA position for impingement-free ROM. We found a functional combined anteversion zone for THA that may be used moving forward to place total hip components. Cite this article: Bone Jt Open 2021;2(10):834–841

Aims. The aim of this study was to investigate whether the use of antibiotic-loaded bone cement influenced the risk of revision surgery after primary total hip arthroplasty (THA) for osteoarthritis. Methods. The study involved data collected by the National Joint Registry (NJR) for England and Wales, Northern Ireland and the Isle of Man between 1 September 2005 and 31 August 2017. Cox proportional hazards were used to investigate the association between use of antibiotic-loaded bone cement and the risk of revision due to prosthetic joint infection (PJI), with adjustments made for the year of the initial procedure, age at the time of surgery, sex, American Society of Anesthesiologists (ASA) grade, head size, and body mass index (BMI). We looked also at the association between use of antibiotic-loaded bone cement and the risk of revision due to aseptic loosening or osteolysis. Results. The cohort included 418,857 THAs of whom 397,896 had received antibiotic-loaded bone cement and 20,961 plain cement. After adjusting for putative confounding factors, the risk of revision for PJI was lower in those in whom antibiotic-loaded bone cement was used (hazard ration (HR) 0.79; 95% confidence interval (CI) 0.64 to 0.98). There was also a protective effect on the risk of revision due to aseptic loosening or osteolysis, in the period of > 4.1 years after primary THA, HR 0.57, 95% CI 0.45, 0.72. Conclusion. Within the limits of registry analysis, this study showed an association between the use of antibiotic-loaded bone cement and lower rates of revision due to PJI. The findings support the continued use of antibiotic-loaded bone cement in cemented THA. Cite this article: Bone Joint J 2020;102-B(8):997–1002

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. Total hip arthroplasty (THA) patients undergoing or having a prior lumbar spine fusion (LSF) have an increased risk of mechanical complications. The aim of this registry-based, retrospective comparative cohort study is to assess the longer term survival of THA in patients who have undergone a LSF during a 17-year period (2000 to 2017). Methods. A registry-based population study was conducted on 679 patients who underwent both THA and LSF surgeries. Patients were identified from the regional arthroplasty data base and cross linked to patients with LSF from the regional hospital discharge database between 2000 and 2017. Demographic data, diagnosis leading to primary THA, primary implant survival, perioperative complications, number and causes of failure, and patients requiring revision arthroplasty were collated and compared. For comparison, data from 67,919 primary THAs performed during the same time time period were also retrieved and analyzed. Results. Patients undergoing THA and LSF showed homogeneous demographic data compared to those undergoing THA alone, but a significantly lower eight-year THA implant survival (96.7 vs 96.0, p = 0.024) was observed. Moreover, THA plus LSF patients showed increased incidence of mechanical complications in the first two years after THA surgery compared to THA alone patients. Conclusion. This registry-based population study shows that approximately 679 (1%) THA patients were subjected to LSF. Patients undergoing THA and LSF have an increased risk of mechanical complications with their THA and a slightly increased risk of revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(3):486–491

Aims. This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy. Methods. Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review. Results. Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers’ compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy. Conclusion. Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822–831

Aims. The aim of this study was to assess the influence of operating time on 30-day complications following total hip arthroplasty (THA). Patients and Methods. We identified patients aged 18 years and older who underwent THA between 2006 and 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We identified 131 361 patients, with a mean age of 65 years (. sd. 12), who underwent THA. We used multivariable regression to determine if the rate of complications and re-admissions was related to the operating time, while adjusting for relevant covariables. Results. The mean operating time decreased from 118.3 minutes (29.0 to 217.0) in 2006, to 89.6 minutes (20.0 to 240.0) in 2016. After adjustment for covariables, operating times of between 90 and 119 minutes increased the risk of minor complications by 1.2 (95% confidence interval (CI) 1.1 to 1.3), while operating times of between 120 and 179 minutes increased the risk of major complications by 1.4 (95% CI 1.3 to 1.6) and minor complications by 1.4 (95% CI 1.2 to 1.5), and operating times of 180 minutes or more increased the risk of major complications by 2.1 (95% CI 1.8 to 2.6) and minor complications by 1.9 (95% CI 1.6 to 2.3). There was no difference in the overall risk of complications for operating times of between 20 and 39, 40 and 59, or 60 and 89 minutes (p > 0.05). Operating times of between 40 and 59 minutes decreased the risk of re-admission by 0.88 (95% CI 0.79 to 0.97), while operating times of between 120 and 179 minutes, and of 180 minutes or more, increased the risk of re-admission by 1.2 (95% CI 1.1 to 1.3) and 1.6 (95% CI 1.3 to 1.8), respectively. Conclusion. These findings suggest that an operating time of more than 90 minutes may be an independent predictor of major and minor complications, as well as re-admission, following THA, and that an operating time of between 40 and 90 minutes may be ideal. Prospective studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B(6 Supple B):51–56

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. Methods. A retrospective review was undertaken of 980 primary cemented THAs in 876 patients using cemented acetabular components with the IBBC technique. The outcome variable was any RLLs that could be observed around the acetabular component at the first year after THA. Univariate analyses with univariate logistic regression and multivariate analyses with exact logistic regression were performed to identify risk factors for any RLLs based on radiological classification of hip osteoarthritis. Results. RLLs were detected in 27.2% of patients one year postoperatively. In multivariate regression analysis controlling for confounders, atrophic osteoarthritis (odds ratio (OR) 2.17 (95% confidence interval (CI), 1.04 to 4.49); p = 0.038) and 26 mm (OR 3.23 (95% CI 1.85 to 5.66); p < 0.001) or 28 mm head diameter (OR 3.64 (95% CI 2.07 to 6.41); p < 0.001) had a significantly greater risk for any RLLs one year after surgery. Structural bone graft (OR 0.19 (95% CI 0.13 to 0.29) p < 0.001) and location of the hip centre within the true acetabular region (OR 0.15 (95% CI 0.09 to 0.24); p < 0.001) were significantly less prognostic. Improvement of the cement-bone interface including complete disappearance and poorly defined RLLs was identified in 15.1% of patients. Kaplan-Meier survival analysis for the acetabular component at ten years with revision of the acetabular component for aseptic loosening as the end point was 100.0% with a RLL and 99.1% without a RLL (95% CI 97.9 to 100). With revision of the acetabular component for any reason as the end point, the survival rate was 99.2% with a RLL (95% CI 97.6 to 100) and 96.5% without a RLL (95% CI 93.4 to 99.7). Conclusion. This study demonstrates that acetabular bone quality, head diameter, structural bone graft, and hip centre position may influence the presence of the any RLL. Cite this article: Bone Joint Open 2021;2(5):278–292

Aims. To investigate the effect of polyethylene manufacturing characteristics and irradiation dose on the survival of cemented and reverse hybrid total hip arthroplasties (THAs). Methods. In this registry study, data from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man (NJR) were linked with manufacturing data supplied by manufacturers. The primary endpoint was revision of any component. Cox proportional hazard regression was a primary analytic approach adjusting for competing risk of death, patient characteristics, head composition, and stem fixation. Results. A total of 290,770 primary THAs were successfully linked with manufacturing characteristics. Overall 4,708 revisions were analyzed, 1,260 of which were due to aseptic loosening. Total radiation dose was identified as a risk factor and included in the Cox model. For statistical modelling of aseptic loosening, THAs were grouped into three categories: G1 (no radiation); G2 ( > 0 to < 5 Mrad); and G3 ( ≥ 5 Mrad). G1 had the worst survivorship. The Cox regression hazard ratio for revision due to aseptic loosening for G2 was 0.7 (95% confidence interval (CI) 0.58 to 0.83), and for G3 0.4 (95% CI 0.30 to 0.53). Male sex and uncemented stem fixation were associated with higher risk of revision and ceramic heads with lower risk. Conclusion. Polyethylene irradiation was associated with reduced risk of revision for aseptic loosening. Radiation doses of ≥ 5 Mrad were associated with a further reduction in risk. Cite this article: Bone Joint Res 2020;9(9):563–571

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. Materials and Methods. We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum. Results. There were 151 patients who met the classification of high-risk according to the inclusion criteria and received DM THA during the study period. Mean age was 82 years old (73 to 95) and 114 patients (77.5%) were female. Mean follow-up was 3.6 years (1.9 to 6.1), with five patients lost to follow-up and one patient who died (for a reason unrelated to the index procedure). One patient (0.66%) sustained an intraprosthetic dislocation; there were no other dislocations. Conclusion. At mid-term follow-up, the use of a DM bearing for primary THA in patients at high risk of dislocation provided a stable reconstruction option with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions

Aims. Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip. Patients and Methods. We used nationwide linked discharge data from the Healthcare Cost and Utilization Project between 2005 and 2014 to analyze the incidence and recurrence of complications following the first- and second-stage operations in staged bilateral total hip arthroplasty (BTHAs). Complications included perioperative medical adverse events within 30 to 60 days, and infection and mechanical complications within one year. Conditional probabilities and odds ratios (ORs) were calculated to determine whether experiencing a complication after the first stage of surgery increased the risk of developing the same complication after the second stage. Results. A total of 13 829 patients (5790 men and 8039 women) who underwent staged BTHAs were analyzed. The mean age at first operation was 62.9 years (14 to 95). For eight of the 12 outcomes evaluated, patients who experienced the outcome following the first arthroplasty had a significantly increased probability and odds of developing that same complication following the second arthroplasty, compared with those who did not experience the complication after the first surgery. This was true for digestive complications (OR 25.67, 95% confidence interval (CI) 13.86 to 46.08; p < 0.001), urinary complications (OR 6.48, 95% CI 1.7 to 20.73; p = 0.01), haematoma (OR 12.17, 95% CI 4.55 to 31.14; p < 0.001), deep vein thrombosis (OR 4.82, 95% CI 2.34 to 9.65; p < 0.001), pulmonary embolism (OR 12.03, 95% CI 2.02 to 46.77; p = 0.01), deep hip infection (OR 534.21, 95% CI 314.96 to 909.25; p < 0.001), superficial hip infection (OR 1574.99, 95% CI 269.83 to 9291.81; p < 0.001), and mechanical malfunction (OR 117.49, 95% CI 91.55 to 150.34; p < 0.001). Conclusion. The occurrence of certain complications after unilateral THA is associated with an increased risk of the same complication occurring after staged arthroplasty of the contralateral hip. Patients who experience these complications after unilateral hip arthroplasty should be appropriately counselled regarding their risk profile prior to undergoing staged contralateral hip arthroplasty. Cite this article: Bone Joint J 2019;101-B(6 Supple B):77–83

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. Patients and Methods. We identified 84 patients (97 THAs) between 1998 and 2015 who had undergone spinal fusion prior to primary THA. Patients were stratified into three groups depending on the length of lumbar fusion and whether or not the sacrum was involved. Mean age was 71 years (40 to 87) and 54 patients (56%) were female. The mean body mass index (BMI) was 30 kg/m. 2. (19 to 45). Mean follow-up was six years (2 to 17). Patients were 1:2 matched to patients with primary THAs without spine fusion. Hazard ratios (HR) were calculated. Results. Dislocation in the fusion group was 5.2% at one year versus 1.7% in controls but this did not reach statistical significance (HR 1.9; p = 0.33). Compared with controls, there was no significant difference in rate of dislocation in patients without a sacral fusion. When the sacrum was involved, the rate of dislocation was significantly higher than in controls (HR 4.5; p = 0.03), with a trend to more dislocations in longer lumbosacral fusions. Patient demographics and surgical characteristics of THA (i.e. surgical approach and femoral head diameter) did not significantly impact risk of dislocation (p > 0.05). Significant radiological differences were measured in mean anterior pelvic tilt between the one-level lumbar fusion group (22°), the multiple-level fusion group (27°), and the sacral fusion group (32°; p < 0.01). Ten-year survival was 93% in the fusion group and 95% in controls (HR 1.2; p = 0.8). Conclusion. Lumbosacral spinal fusions prior to THA increase the risk of dislocation within the first six months. Fusions involving the sacrum with multiple levels of lumbar involvement notably increased the risk of postoperative dislocation compared with a control group and other lumbar fusions. Surgeons should take care with component positioning and may consider higher stability implants in this high-risk cohort

Aims. This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty. Methods. Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type. Results. A total of 584 cases were included. Median age was 79.1 years (interquartile range 72.0 to 86.0), 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The most common AO/OTA type was spiral (352, 60.3%). Metaphyseal split fractures occurred only with PTS stems with an incidence of 10.1%. Male sex was associated with a five-fold reduction in odds of a type C fracture (OR 0.22 (95% CI 0.12 to 0.41); p < 0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51 (95% CI 3.72 to 24.34); p < 0.001) and wedge fracture (OR 3.72 (95% CI 1.16 to 11.95); p = 0.027) compared to PTS stems. Both UCS grade and AO/OTA type differed significantly (p < 0.001 and p = 0.001, respectively) between the revision and fixation groups but a similar proportion of B1 fractures underwent revision compared to fixation (45.3% vs 50.6%). Conclusion. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems have higher odds of bending type fractures (transverse and wedge) compared to PTS stems. There is considerable variation in practice when treating B1 fractures around cemented stems. Cite this article: Bone Jt Open 2021;2(7):466–475

Aims. There is evidence that prior lumbar fusion increases the risk of dislocation and revision after total hip arthroplasty (THA). The relationship between prior lumbar fusion and the effect of femoral head diameter on THA dislocation has not been investigated. We examined the relationship between prior lumbar fusion or discectomy and the risk of dislocation or revision after THA. We also examined the effect of femoral head component diameter on the risk of dislocation or revision. Methods. Data used in this study were compiled from several Finnish national health registers, including the Finnish Arthroplasty Register (FAR) which was the primary source for prosthesis-related data. Other registers used in this study included the Finnish Health Care Register (HILMO), the Social Insurance Institutions (SII) registers, and Statistics Finland. The study was conducted as a prospective retrospective cohort study. Cox proportional hazards regression and Kaplan-Meier survival analysis were used for analysis. Results. Prior lumbar fusion surgery was associated with increased risk of prosthetic dislocation (hazard ratio (HR) = 2.393, p < 0.001) and revision (HR = 1.528, p < 0.001). Head components larger than 28 mm were associated with lower dislocation rates compared to the 28 mm head (32 mm: HR = 0.712, p < 0.001; 36 mm: HR = 0.700, p < 0.001; 38 mm: HR = 0.808, p < 0.140; and 40 mm: HR = 0.421, p < 0.001). Heads of 38 mm (HR = 1.288, p < 0.001) and 40 mm (HR = 1.367, p < 0.001) had increased risk of revision compared to the 28 mm head. Conclusion. Lumbar fusion surgery was associated with higher rate of hip prosthesis dislocation and higher risk of revision surgery. Femoral head component of 32 mm (or larger) associates with lower risk of dislocation in patients with previous lumbar fusion. Cite this article: Bone Joint J 2020;102-B(8):1003–1009

Aims

The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component.

Aims. The aim of this study was to determine whether patients with metal-on-metal (MoM) arthroplasties of the hip have an increased risk of cardiac failure compared with those with alternative types of arthroplasties (non-MoM). Patients and Methods. A linkage study between the National Joint Registry, Hospital Episodes Statistics and records of the Office for National Statistics on deaths was undertaken. Patients who underwent elective total hip arthroplasty between January 2003 and December 2014 with no past history of cardiac failure were included and stratified as having either a MoM (n = 53 529) or a non-MoM (n = 482 247) arthroplasty. The primary outcome measure was the time to an admission to hospital for cardiac failure or death. Analysis was carried out using data from all patients and from those matched by propensity score. Results. The risk of cardiac failure was lower in the MoM cohort compared with the non-MoM cohort (adjusted hazard ratio (aHR) 0.901; 95% confidence interval (CI) 0.853 to 0.953). The risk of cardiac failure was similar following matching (aHR 0.909; 95% CI 0.838 to 0.987) and the findings were consistent in subgroup analysis. Conclusion. The risk of cardiac failure following total hip arthroplasty was not increased in those in whom MoM implants were used, compared with those in whom other types of prostheses were used, in the first seven years after surgery. Cite this article: Bone Joint J 2018;100-B:20–7

Aims. The aim of this study was to identify the effect of the manufacturing characteristics of polyethylene acetabular liners on the survival of cementless and hybrid total hip arthroplasty (THA). Methods. Prospective cohort study using linked National Joint Registry (NJR) and manufacturer data. The primary endpoint was revision for aseptic loosening. Cox proportional hazard regression was the primary analytical approach. Manufacturing variables included resin type, crosslinking radiation dose, terminal sterilization method, terminal sterilization radiation dose, stabilization treatment, total radiation dose, packaging, and face asymmetry. Total radiation dose was further divided into G1 (no radiation), G2 (> 0 Mrad to < 5 Mrad), G3 (≥ 5 Mrad to < 10 Mrad), and G4 (≥ 10 Mrad). Results. A total of 5,329 THAs were revised, 1,290 of which were due to aseptic loosening. Total radiation dose, face asymmetry, and stabilization treatments were found to significantly affect implant survival. G1 had the highest revision risk for any reason and for aseptic loosening and G3 and G4 the lowest. Compared with G1, the adjusted hazard ratio for G2 was 0.74 (95% confidence interval (CI) 0.64 to 0.86), G3 was 0.36 (95% CI 0.30 to 0.43), and G4 was 0.38 (95% CI 0.31 to 0.47). The cumulative incidence of revision for aseptic loosening at 12 years was 0.52 and 0.54 per 100 THAs for G3 and G4, respectively, compared with 1.95 per 100 THAs in G1. Asymmetrical liners had a lower revision risk due to aseptic loosening and reasons other than aseptic loosening compared with symmetric (flat) liners. In G3 and G4, stabilization with vitamin E and heating above melting point performed best. Conclusion. Polyethylene liners with a total radiation dose of ≥ 5 Mrad, an asymmetrical liner face, and stabilization with heating above the melting point demonstrate best survival. Cite this article: Bone Joint J 2020;102-B(1):90–101

Aims. The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. Patients and Methods. A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation. Results. In the base case, patients with a spinal deformity were modelled to have an 8% probability of dislocation following primary THA based on published clinical ranges. Sensitivity analysis revealed that, at its current average price ($1000), DM is cost-effective if it reduces the probability of dislocation to 0.9%. The threshold cost at which DM ceased being cost-effective was $1180, while the ICER associated with a DM THA was $71 000 per QALY. Conclusion. These results indicate that under specific clinical and economic thresholds, DM components are a cost-effective form of treatment for patients with spinal deformity who are at high risk of dislocation after THA. Cite this article: Bone Joint J 2018;100-B:1297–1302

Aims. The purpose of this study was to determine the lifetime risk of revision surgery for patients undergoing Charnley cemented total hip arthroplasty (THA), with 40-year follow up, using death as a competing risk. . Materials and Methods. We retrospectively reviewed 2000 cemented Charnley THAs, with 51 living hips available at 40 years. . Results. The cumulative risk of revision or removal for any reason was 13% (95% confidence interval (CI) 12 to 15). Patients aged under 50 years at the time of surgery had a 35% (95% CI 28 to 42) risk of revision or removal for any reason (Hazard Ratio (HR) 3.6; 95% CI 2.5 to 5.2; p <  0.001), patients 50 to 59 years old had a 20% risk (95% CI 16 to 24) (HR 2.1; 95% CI 1.5 to 2.8; p < 0.0001), patients aged 60 to 69 years had a 9% risk (95% CI 7 to 11) (reference point), and patients ≥ 70 years old had a 5% risk (95% CI 4 to 7) (HR 0.96; 95% CI 0.6 to 1.5; p = 0.86) during their lifetime. Men had a higher risk of revision or removal for any reason (HR 2.1; 95% CI 1.7 to 2.7; p < 0.001). . Conclusion. With almost all the patients in this series followed up till either death or revision, we have been able to develop a ‘rule of thumb’ for lifetime likelihood of revision or implant removal for the Charnley THA: one in three for patients < 50 years, one in five for patients 50 to 59 years, one in ten for patients 60 to 69 years, and one in 20 for patients ≥ 70 years. The results provide a benchmark for comparison of outcomes, for the newer designs of THA. . Cite this article: Bone Joint J 2016;98-B:1436–40

Aims. It has been suggested that cemented fixation of total hip arthroplasty (THA) is associated with an increased peri-operative mortality compared with cementless THA. Our aim was to investigate this through a nationwide matched cohort study adjusting for age, comorbidity, and socioeconomic background. Patients and Methods. A total of 178 784 patients with osteoarthritis who underwent either cemented or cementless THA from the Swedish Hip Arthroplasty Register were matched with 862 294 controls from the general population. Information about the causes of death, comorbidities, and socioeconomic background was obtained. Mortality within the first 90 days after the operation was the primary outcome measure. Results. Patients who underwent cemented THA had an increased risk of death during the first 14 days compared with the controls (hazard ratio (HR) 1.3, confidence interval (CI) 1.11 to 1.44), corresponding to an absolute increase in risk of five deaths per 10 000 observations. No such early increase of risk was seen in those who underwent cementless THA. Between days 15 and 29 the risk of mortality was decreased for those with cemented THA (HR 0.7, CI 0.62 to 0.87). Between days 30 and 90 all patients undergoing THA, irrespective of the mode of fixation, had a lower risk of death than controls. Patients selected for cementless fixation were younger, healthier and had a higher level of education and income than those selected for cemented THA. A supplementary analysis of 16 556 hybrid THAs indicated that cementation of the femoral component was associated with a slight increase in mortality up to 15 days, whereas no such increase in mortality was seen in those with a cemented acetabular component combined with a cementless femoral component. Conclusion. This nationwide matched cohort study indicates that patients receiving cemented THA have a minimally increased relative risk of early mortality that is reversed from day 15 and thereafter. The absolute increase in risk is very small. Our findings lend support to the idea that cementation of the femoral component is more dangerous than cementation of the acetabular component. Cite this article: Bone Joint J 2017;99-B:37–43

Aims. It is important to consider sagittal pelvic rotation when introducing the acetabular component at total hip arthroplasty (THA). The purpose of this study was to identify patients who are at risk of unfavourable pelvic mobility, which could result in poor outcomes after THA. Patients and Methods. A consecutive series of 4042 patients undergoing THA had lateral functional radiographs and a low-dose CT scan to measure supine pelvic tilt, pelvic incidence, standing pelvic tilt, flexed-seated pelvic tilt, standing lumbar lordotic angle, flexed-seated lumbar lordotic angle, and lumbar flexion. Changes in pelvic tilt from supine-to-standing positions and supine-to-flexed-seated positions were determined. A change in pelvic tilt of 13° between positions was deemed unfavourable as it alters functional anteversion by 10° and effectively places the acetabular component outside the safe zone of orientation. Results. For both men and women, the degree of lumbar flexion was a significant predictor of risk in hip flexion (p < 0.0001) with increased odds of unfavourable pelvic mobility in those with lumbar flexion of < 20° (men, odds ratio (OR) 6.74, 95% confidence interval (CI) 3.83 to 11.89; women, OR 2.97, 95% CI 1.87 to 4.71). In women, age and standing pelvic tilt were significant predictors of risk in hip extension (p = 0.0082 and p < 0.0001, respectively). The risk of unfavourable pelvic mobility was higher in those aged > 75 years (OR 2.28, 95% CI 1.56 to 3.32) and those with standing pelvic tilt of < -10° for extension risk (OR 7.10, 95% CI 4.10 to 10.29). In men, only standing pelvic tilt was significant (p < 0.0001) for hip extension with an increased risk of unfavourable pelvic mobility (OR 8.68, 95% CI 5.19 to 14.51). Conclusion. Patients found to have unfavourable pelvic mobility had limited lumbar flexion and more posterior standing pelvic tilt in both men and women, as well as increasing age in women. We recommend that patients undergo preoperative functional radiographic screening to determine specific parameters that can affect the functional orientation of the acetabular component. Cite this article: Bone Joint J 2018;100-B:845–52

We have evaluated the extent to which diabetes affects the revision rate following total hip replacement (THR). Through the Danish Hip Arthroplasty Registry we identified all patients undergoing a primary THR (n = 57 575) between 1 January 1996 and 31 December 2005, of whom 3278 had diabetes. The presence of diabetes among these patients was identified through the Danish National Registry of Patients and the Danish National Drug Prescription Database. We estimated the relative risk for revision and the 95% confidence intervals for patients with diabetes compared to those without, adjusting for the confounding factors. Diabetes is associated with an increased risk of revision due to deep infection (relative risk = 1.45 (95% confidence interval 1.00 to 2.09), particularly in those with type 2 diabetes (relative risk = 1.49 (95% confidence interval 1.02 to 2.18)), those with diabetes for less than five years prior to THR (relative risk = 1.69 (95% confidence interval 1.24 to 2.32)), those with complications due to diabetes (relative risk = 2.11 (95% confidence interval 1.41 to 3.17)), and those with cardiovascular comorbidities prior to surgery (relative risk = 2.35 (95% confidence interval 1.39 to 3.98)). Patients and surgeons should be aware of the relatively elevated risk of revision due to deep infection following THR in diabetes particularly in those with insufficient control of their glucose level

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. Methods. Two matching cohorts were created from a collection of cadaveric specimens with known pelvic incidences: 50 subjects with the highest pelvic incidence (all subjects > 60°) and 50 subjects with the lowest pelvic incidence (all subjects < 35°). Femoral version, acetabular version, and alpha angles were directly measured from each specimen bilaterally. Cam morphology was defined as alpha angle > 55°. Differences between the two cohorts were analysed with a Student’s t-test and the difference in incidence of cam morphology was assessed using a chi-squared test. The significance level for all tests was set at p < 0.05. Results. Cam morphology was identified in 47/100 (47%) femurs in the cohort with pelvic incidence < 35° and in only 25/100 (25%) femurs in the cohort with pelvic incidence > 60° (p = 0.002). The mean alpha angle was also greater in the cohort with pelvic incidence < 35° (mean 53.7°, . sd. 10.7° versus mean 49.7°, . sd. 10.6°; p = 0.008). Conclusions. Decreased pelvic incidence is associated with development of cam morphology. We propose a novel theory wherein subjects with decreased pelvic incidence compensate during gait (to maintain optimal sagittal balance) through anterior pelvic tilt, creating artificial anterior acetabular overcoverage and recurrent impingement that increases risk for cam morphology. Cite this article: W. Z. Morris, C. A. Fowers, R. T. Yuh, J. J. Gebhart, M. J. Salata, R. W. Liu. Decreasing pelvic incidence is associated with greater risk of cam morphology. Bone Joint Res 2016;5:387–392. DOI: 10.1302/2046-3758.59.BJR-2016-0028.R1

We examined the one-year risk of symptomatic venous thromboembolism (VTE) following primary total hip replacement (THR) among Danish patients and a comparison cohort from the general population. From the Danish Hip Arthroplasty Registry we identified all primary THRs performed in Denmark between 1995 and 2010 (n = 85 965). In all, 97% of patients undergoing THR received low-molecular-weight heparin products during hospitalisation. Through the Danish Civil Registration System we sampled a comparison cohort who had not undergone THR from the general population (n = 257 895). Among the patients undergoing THR, the risk of symptomatic VTE was 0.79% between 0 and 90 days after surgery and 0.29% between 91 and 365 days after surgery. In the comparison cohort the corresponding risks were 0.05% and 0.12%, respectively. The adjusted relative risks of symptomatic VTE among patients undergoing THR were 15.84 (95% confidence interval (CI) 13.12 to 19.12) during the first 90 days after surgery and 2.41 (95% CI 2.04 to 2.85) during 91 to 365 days after surgery, compared with the comparison cohort. The relative risk of VTE was elevated irrespective of the gender, age and level of comorbidity at the time of THR. We concluded that THR was associated with an increased risk of symptomatic VTE up to one year after surgery compared with the general population, although the absolute risk is small

Aims. Fretting and corrosion at the modular head/neck junction, known as trunnionosis, in total hip arthroplasty (THA) is a cause of adverse reaction to metal debris (ARMD). We describe the outcome of revision of metal-on-polyethylene (MoP) THA for ARMD due to trunnionosis with emphasis on the risk of major complications. Patients and Methods. A total of 36 patients with a MoP THA who underwent revision for ARMD due to trunnionosis were identified. Three were excluded as their revision had been to another metal head. The remaining 33 were revised to a ceramic head with a titanium sleeve. We describe the presentation, revision findings, and risk of complications in these patients. Results. The patients presented with pain, swelling, stiffness, or instability and an inflammatory mass was confirmed radiologically. Macroscopic material deposition on the trunnion was seen in all patients, associated with ARMD. Following revision, six (18.2%) dislocated, requiring further revision in four. Three (9.1%) developed a deep infection and six (18.2%) had significant persistent pain without an obvious cause. One developed a femoral artery thrombosis after excision of an iliofemoral pseudotumor, requiring a thrombectomy. Conclusion. The risk of serious complications following revision MoP THA for ARMD associated with trunnionosis is high. In the presence of extensive tissue damage, a constrained liner or dual mobility construct is recommended in these patients. Cite this article: Bone Joint J 2018;100-B:720–4

Aims. The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen. Patients and Methods. We evaluated all patients undergoing primary TKA or THA at a single academic institution between January 2004 and May 2017, yielding 29 695 arthroplasties (22 705 patients), with 3411 arthroplasties in 2576 patients (11.5%) having undergone preoperative allergy testing. A series of institutional databases were combined to identify allergy consultation outcomes, perioperative antibiotic regimen, and infection-free survivorship until final follow-up. Results. Among 2576 allergy-tested patients, 2493 patients (97%) were cleared to use cephalosporins. For the entire cohort, 28 174 arthroplasties (94.9%) received cefazolin and 1521 (5.1%) received non-cefazolin antibiotics. Infection-free survivorship was significantly higher among arthroplasties receiving cefazolin compared with non-cefazolin antibiotics, with 0.06% higher survival free of infection at one month, 0.56% at two months, 0.61% at one year, and 1.19% at ten years (p < 0.001). Overall, the risk of PJI was 32% lower in patients treated with cefazolin after adjusting for the American Society of Anesthesiologists (ASA) classification, joint arthroplasty (TKA or THA), and body mass index (BMI; p < 0.001). The number needed to treat with cefazolin to prevent one PJI was 164 patients at one year and 84 patients at ten years. Therefore, potentially 6098 PJIs could be prevented by one year and 11 905 by ten years in a cohort of 1 000 000 primary TKA and THA patients. Conclusion. PJI rates are significantly higher when non-cefazolin antibiotics are used for perioperative TKA and THA prophylaxis, highlighting the positive impact of preoperative antibiotic allergy testing to increase cefazolin usage. Given the low rate of true penicillin allergy positivity, and the readily modifiable risk factor that antibiotic choice provides, we recommend perioperative testing and clearance for all patients presenting with penicillin and cephalosporin allergies. Cite this article: Bone Joint J 2019;101-B(6 Supple B):9–15

Aims. Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods. A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results. The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion. The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation

Aims. The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. Patients and Methods. A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. Results. A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. Conclusion. The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793–799

We examined patient and surgical factors associated with deep surgical site infection (SSI) following total hip replacement (THR) in a large integrated healthcare system. A retrospective review of a cohort of primary THRs performed between 2001 and 2009 was conducted. Patient characteristics, surgical details, surgeon and hospital volumes, and SSIs were identified using the Kaiser Permanente Total Joint Replacement Registry (TJRR). Proportional-hazard regression models were used to assess risk factors for SSI. The study cohort consisted of 30 491 THRs, of which 17 474 (57%) were performed on women. The mean age of the patients in the whole series was 65.5 years (13 to 97; . sd. 11.8) and the mean body mass index was 29.3 kg/m. 2. (15 to 67; . sd. 5.9). The incidence of SSI was 0.51% (155 of 30 491). Patient factors associated with SSI included female gender, obesity, and American Society of Anesthesiologists (ASA) score ≥ 3. Age, diagnosis, diabetes and race were not associated with SSI. The only surgical factor associated with SSI was a bilateral procedure. Surgeon and hospital volumes, use of antibiotic-laden cement, fixation method, laminar flow, body exhaust suits, surgical approach and fellowship training were not associated with risk of SSI. A comprehensive infection surveillance system, combined with a TJRR, identified patient and surgical factors associated with SSI. Obesity and chronic medical conditions should be addressed prior to THR. The finding of increased SSI risk with bilateral THR requires further investigation

Aims. The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana). Patients and Methods. A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture. Results. The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture. Conclusion. Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451–7

Obesity is a risk factor for complications following many orthopaedic procedures. The purpose of this study was to investigate whether obesity was an independent risk factor increasing the rate of complications following periacetabular osteotomy (PAO) and to determine whether radiographic correction after PAO was affected by obesity. . We retrospectively collected demographic, clinical and radiographic data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were followed for a mean of 48 months (12 to 60) after PAO. A total of 65 patients (23.2%) were obese (body mass index (BMI) > 30 kg/m. 2. ). Univariate and multivariate analysis demonstrated that BMI was an independent risk factor associated with the severity of the complications. The average probability of a patient developing a major complication was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient The odds of a patient developing a major complication were 11 times higher (95% CI 4.71 to 17.60, p <  0.0001) for an obese compared with a non-obese patient. . Following PAO surgery, there was no difference in radiographic correction between obese and non-obese patients. PAO procedures in obese patients correct the deformity effectively but are associated with an increased rate of complications. Cite this article: Bone Joint J 2015;97-B:29–34