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. 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. 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. 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 aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate. Methods. This retrospective analysis identified 267 hips from 224 patients who underwent an hip resurfacing arthroplasty (HRA) from a single fellowship-trained surgeon using the direct lateral approach between 2007 and 2019. Inclusion criteria was minimum two-year follow-up, and age younger than 40 years. Patients were followed using a prospectively maintained institutional database. Results. A total of 217 hips (81%) were included for follow-up analysis at a mean of 3.8 years. Of the 23 females who underwent HRA, none were revised, and the median head size was 46 mm (compared to 50 mm for males). The most common indication for HRA was femoroacetabular impingement syndrome (n = 133), and avascular necrosis ( (n = 53). Mean postoperative HHS was 100 at two and five years. No dislocations occurred. A total of four hips (1.8%) required reoperation for resection of heterotopic ossification, removal of components for infection, and subsidence with loosening. The overall revision rate was 0.9%. Conclusion. For younger patients with higher functional expectations and increased lifetime risk for revision, HRA is an excellent bone preserving intervention carrying low complication rates, revision rates, and excellent patient outcomes without lifetime restrictions allowing these patients to return to activity and sport. Thus, in younger male patients with end-stage hip disease and higher demands, referral to a high-volume HRA surgeon should be considered. Cite this article: Bone Jt Open 2023;4(6):408–415

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The objective of this study was to compare the two-year migration and clinical outcomes of a new cementless hydroxyapatite (HA)-coated titanium acetabular shell with its previous version, which shared the same geometrical design but a different manufacturing process for applying the titanium surface.

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This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening.

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The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

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The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs).

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The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

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

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One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

Aims. Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF. Patients and Methods. We analysed data on 257 202 primary THAs with cemented stems and 390 linked first revisions for PF recorded in the National Joint Registry (NJR) of England, Wales and Northern Ireland to determine if a cemented femoral stem brand was associated with the risk of having revision for a PF after primary THA. All cemented femoral stem brands with more than 10 000 primary operations recorded in the NJR were identified. The four most commonly used cemented femoral stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem (n = 15 113) and Charnley (n = 20 182). We compared the revision risk ratios due to PF amongst the stems using a Poisson regression model adjusting for patient factors. Compared with the Exeter V40, the age, gender and ASA grade adjusted revision rate ratio was 3.89 for the cemented CPT stem (95% confidence interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to 1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70). Conclusions. The limitations of the study include incomplete data capture, analysis of only PF requiring revision and that observation does not imply causality. Nevertheless, this study demonstrates that the choice of a cemented stem may influence the risk of revision for PF. Cite this article: Bone Joint J 2016;98-B:1347–54

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

There is little evidence on the cost effectiveness of different brands of hip prostheses. We compared lifetime cost effectiveness of frequently used brands within types of prosthesis including cemented (Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed) and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and CPT Trilogy). We used data from three linked English national databases to estimate the lifetime risk of revision, quality-adjusted life years (QALYs) and cost. . For women with osteoarthritis aged 70 years, the Exeter V40 Elite Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0 QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision risk, 9.3 QALYs). Compared with the Corail Pinnacle (9.3% revision risk, 9.22 QALYs), the most commonly used brand, and assuming a willingness-to-pay of £20 000 per QALY gain, the CPT Trilogy is most cost effective, with an incremental net monetary benefit of £876. Differences in cost effectiveness between the hybrid CPT Trilogy and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc Exceed were small, and a cautious interpretation is required, given the limitations of the available information. However, it is unlikely that cemented brands are among the most cost effective. Similar patterns of results were observed for men and other ages. The gain in quality of life after total hip arthroplasty, rather than the risk of revision, was the main driver of cost effectiveness. Cite this article: Bone Joint J 2015;97-B:762–70

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

Aims. 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. 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. We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. Patients and Methods. This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression. Results. Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery versus uncomplicated THA (p < 0.001). Conclusion. IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: Bone Joint J 2019;101-B:1199–1208

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Vitamin E-diffused, highly crosslinked polyethylene (VEPE) and porous titanium-coated (PTC) shells were introduced in total hip arthroplasty (THA) to reduce the risk of aseptic loosening. The purpose of this study was: 1) to compare the wear properties of VEPE to moderately crosslinked polyethylene; 2) to assess the stability of PTC shells; and 3) to report their clinical outcomes at seven years.