The 22 year survivorship of metal on metal hip resurfacing arthroplasty (RSA) is reported to be 94.3% with expert surgeons, in males with head sizes greater than 48mm. The 2023 National Joint Registry (NJR) report estimates survivorship of all RSA at 19 years to be 85%. This estimate includes all designs, head sizes and females. Our aim was to estimate the survivorship of RSA currently available for implantation (males only, head size >48mm, MatOrtho Adept or Smith and Nephew Birmingham Hip Resurfacing (BHR)) in those under 55 years, performed by all surgeons, compared to conventional THR. We performed a retrospective analysis of the NJR. We included all males under 55 years who had undergone BHR or Adept RSA with head size greater than 48mm. Propensity score matching was used to produce two comparable groups of patients for RSA or conventional THR. We matched in a 3:1 ratio (THR:RSA) using sex, ASA, BMI group, age at primary procedure, surgeon volume, diagnosis and surgeon grade as covariates. The primary analysis was survivorship at 18 years. Time-to-revision was assessed using Kaplan-Meier curves. Cox's proportional hazard models were used to investigate between group differences. 4839 RSA were available for analysis. After matching the RSA and THR groups were well balanced in terms of covariates. Survivorship at 18 years was 93.7% (95% CI 89.9,96.2) in the RSA group and 93.9% (90.5,96.0) in the THR group. Despite these similar estimates the adjusted hazard ratio was 1.40 (95% CI 1.18, 1.67 p<0.001) in favour of THR. Survivorship of the currently available RSA in males under 55 was 93.7% at 18 years, however THR survivorship was superior to RSA. These results, generalisable to UK practice, should be set against perceived benefits in functional status offered in RSA when counselling patients.
Extracapsular Hip Fractures (EHF's) are a significant health burden on healthcare services. Optimal treatment is controversial with conflicting evidence being reported. Currently treatment is undertaken with Intramedullary Nail (IMN) or Dynamic Hip Screw (DHS) constructs with a recent increase in IMN use (1). This study aims to conduct a systematic review of Randomised Control Trials published between 2020 and 2023 with particular focus on patient demographics and holistic patient outcomes. Using a unified search-protocol, RCT's published between 2020 and 2023 were collected from CENTRAL, PubMed, MEDLINE and EMBASE. Rayyan software screened duplicates. Using the CASP and Cochrane Risk of Bias Tool papers were critically examined twice, and Blood Loss, Infection and Mobility described the patient journey. Patient demographics were recorded and were contrasted with geographically diverse cohort studies to compare population differences. Parametric tests were used to determine significance levels between population demographics, namely Age and Sex. Eleven papers were included, representing 908 patients (436 Male). The mean age for patients was 64.39. There was considerable risk of bias in 7/11 studies owing to the randomization process and the recording of data. Four Cohort studies were selected for comparison representing 14314 patients. Mean age was significantly different between Cohort Studies and RCT's (Independent T-Test, df 13, t=7.8, p = <0.001, mean difference = 19.251, 95% CI = 13.888, 24.613). This was also true for sex ratios included in the studies (df 13, t = -2.268, p = 0.024, Mean Difference = -0.4884, 95% CI = -0.9702, -0.0066). To conclude, RCT's published in the post COVID-19 era are not representative of patient demographics. This has the potential to provide inaccurate information for implant selection. Additionally further research must be conducted in how to better improve RCT patient inclusion so as to be more representative of patients whilst balancing the risks of operations.
The aim of this study was to analyze and compare clinical, radiological and mortality outcomes of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures using a SPAIRE technique when compared to a pair-matched control cohort who underwent the same procedure using the direct lateral approach. A retrospective review of patients who underwent cemented hip hemiarthroplasty for displaced neck of femur fractures by a single surgeon using a SPAIRE technique over a two-year period between July 2019 and July 2021 was performed. These were subsequently pair matched in a 5:1 ratio for age, gender, ASA grade and residential status with a control group who underwent cemented hip hemiarthroplasty by 4 other surgeons using a direct lateral approach The study included a total of 240 patients (40 and 200 pairmatched to SPAIRE and control groups respectively), with a mean age of 81.0 ± 8.2 years (63–99) and a mean follow-up of 12 ± 3 months (3–30). Overall, there was no significant difference in any of the radiological or mortality outcome scores assessed between the SPAIRE and control groups (p > 0.05 for all). There was a significantly lower number of patients in the SPAIRE group who dropped a level of mobility from their pre-injury baseline at 30-days post-operatively (8.1% versus 31.6%; p = 0.003). However, this appeared to have resolved at 120-day follow-up with no significant differences between the groups in terms of those acquiring a new baseline mobility at 120-days post-operatively (2.7% versus 13.2%, p = 0.09). In cases of cemented hip hemiarthroplasty for displaced intracapsular neck of femur fractures, the SPAIRE technique appears to offer patients an earlier return to levels of baseline pre-injury mobility when compared to a direct lateral approach.
This study used a national registry to assess the outcomes of hip arthroscopy (HA) for the treatment femoroacetabular impingement (FAI). All HAs for FAI recorded in the UK Non-Arthroplasty Hip Registry (NAHR) between January 2012 and September 2023 were identified. Cases were grouped according to the index procedure performed for FAI (cam, pincer, or mixed). Patient outcomes captured included the International Hip Outcome Tool (iHOT)-12. 7,511 HAs were identified; 4,583 cam (61%), 675 pincer (9%), 2,253 mixed (30%). Mean age (34.8) was similar between groups. There was a greater proportion of females in the pincer group (75%) compared to cam (52%) and mixed (50%). A higher proportion of patients had a recorded cartilage injury in association with a cam lesion compared to pincer. The pincer group had poorer mean pre-op iHOT-12 scores (31.6 \[95%CI 29.9 to 33.3\]; n=364) compared to cam (33.7 \[95%CI 32.1 to 34.4\]; n=3,941) and achieved significantly lower scores at 12 months (pincer = 52.6 (50.2 to 55); n=249, cam = 58.3 (57.1 to 59.5); n=1,679). Overall, significant (p < 0.0001) iHOT-12 and EQ-5D improvement vs baseline pre-operative scores were achieved for all FAI subtypes at 6 months (overall mean iHOT-12 improvement +26.0 \[95%CI 25.0 to 26.9\]; n=2,983) and maintained out to 12 months (+26.2 \[25.1 to 27.2\]; n=2,760) at which point 67% and 48% of patients continued to demonstrate a score improvement greater than or equal to the minimum clinically important difference (>/=13 points) and substantial clinical benefit (>/=28 points) for iHOT-12 respectively. This study demonstrates excellent early functional outcomes following HA undertaken for FAI in a large national registry.
There is little known about how patient socioeconomic status impacts clinical outcomes in hip preservation surgery. The aim of this study was to evaluate the relationship between indices of multiple deprivation, funding provider (NHS Funded or Private Funded) and clinical outcomes following surgery for femoroacetabular impingement (FAI) The study analysed the data of 5590 patients recorded in the NAHR who underwent primary hip arthroscopic treatment for FAI between November 2013 and July 2023. Records were matched to the UK National index of multiple deprivation using the lower layer super output area. Using iHOT12 score, patient reported outcome measures were analysed at base line and 1 year following surgery. 2358 records were matched to LLSOA deciles. Between the lowest (most deprived) 3 deciles and the highest (least deprived) the average baseline iHOT12 score was 28.98 (n=366) and 35.33 (n=821). The proportion of patients receiving treatment through NHS funding compared to independent funding for the most deprived, 292 (90%) 37 (10%) respectively compared to the least deprived 515 (70%) and 244 (30%) respectively. At 1year, iHOT12 scores for each group were 51.64 (29.1 SD) compared to 61.5 (28.06 SD) respectively. The study demonstrates that patients from lower socioeconomic backgrounds had poorer baseline and one-year post-surgery iHOT12 scores compared to those from higher socioeconomic strata. Furthermore, a higher reliance on NHS funding was observed among the most deprived, while more affluent patients predominantly opted for private funding. These findings underscore the significant influence of socioeconomic status on both the quality of healthcare received and recovery outcomes in hip preservation surgery, calling attention to the need for more equitable healthcare solutions.
Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11). In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation. A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database. In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%. In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system.
The increased torque required to dislocate dual mobility (DM) components may increase peri-prosthetic femoral fracture (PPF) risk. Current literature often relies on revision as an endpoint and may underestimate PPF. This study aims to review PPF rate, risks and treatment following primary DM implantation. Prospective cohort study of 549 patients following primary DM total hip arthroplasty (THA) between 2013 and 2021. Collected data included demographics, indication for surgery, cortical index and PPF. 549 patients were identified with primary DM THA. Mean age was 73 years (26–96). 446 (81.2%) patients had their index surgery following hip fracture. 18 patients (3.27%) sustained a PPF. Cumulative PPF rate was 1.5% at 1-year, 2.2% at 5-years and 3.27% overall. PPF was higher in patients undergoing surgery following hip fracture (4%) vs. other indications (1%). OR 4.04 (95% CI:0.53, 30.72), p=0.219. Mean cortical index was lower in patients with PPF 0.4 (95% CI:0.36, 0.45) compared to those without 0.46 (95% CI:0.45, 0.46) p=0.029. Treatment for PPF included 10 (55.6%) open reduction internal fixation (ORIF), 7 (38.9%) revision THA and 1 conservatively managed. PPF rate following DM use is higher in our cohort than published rates. Our rates are comparable to some papers when subgroup analysis of older patients and cemented taper slip stems are considered. PPF risk with DM may be increased in patients undergoing surgery after hip fracture or with a lower cortical index preoperatively. Over half of PPF were managed with ORIF and may mask PPF risk studies that report using revision as an endpoint.
Femoroacetabular Impingement (FAI) syndrome, characterised by abnormal hip contact causing symptoms and osteoarthritis, is measured using the International Hip Outcome Tool (iHOT). This study uses machine learning to predict patient outcomes post-treatment for FAI, focusing on achieving a minimally clinically important difference (MCID) at 52 weeks. A retrospective analysis of 6133 patients from the NAHR who underwent hip arthroscopic treatment for FAI between November 2013 and March 2022 was conducted. MCID was defined as half a standard deviation (13.61) from the mean change in iHOT score at 12 months. SKLearn Maximum Absolute Scaler and Logistic Regression were applied to predict achieving MCID, using baseline and 6-month follow-up data. The model's performance was evaluated by accuracy, area under the curve, and recall, using pre-operative and up to 6-month postoperative variables. A total of 23.1% (1422) of patients completed both baseline and 1-year follow-up iHOT surveys. The best results were obtained using both pre and postoperative variables. The machine learning model achieved 88.1% balanced accuracy, 89.6% recall, and 92.3% AUC. Sensitivity was 83.7% and specificity 93.5%. Key variables determining outcomes included MCID achievement at 6 months, baseline iHOT score, 6-month iHOT scores for pain, and difficulty in walking or using stairs. The study confirmed the utility of machine learning in predicting long-term outcomes following arthroscopic treatment for FAI. MCID, based on the iHOT 12 tools, indicates meaningful clinical changes. Machine learning demonstrated high accuracy and recall in distinguishing between patients achieving MCID and those who did not. This approach could help early identification of patients at risk of not meeting the MCID threshold one year after treatment.
In this study, we examined the impact of dual-mobility (DM) versus fixed-bearing (FB) implants on outcomes following total hip arthroplasty (THA), a common and successful operation. We examined all-cause revision, revision due to dislocation, postoperative complications and functional scores in patients undergoing primary and revision THA. A systematic review was performed according to PRISMA guidelines, and was registered in PROSPERO (ID CRD42023403736). The Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus were searched from inception to 12th March 2023. Eligible studies underwent meta-analysis and methodological assessment using the ROBINS-I tool. Data were pooled using a random-effects maximum-likelihood model. Eight comparative, non-randomised studies involving 2,810 DM implants and 3,188 FB implants were included. In primary THA, the difference in all-cause revision was imprecise (OR 0.82, 95% CI 0.25–2.72), whilst the DM cohort had a statistically significant benefit in revision due to dislocation (OR 0.08, 95% CI 0.02–0.28). In revision THA, the DM cohort showed significant benefit in all-cause revision (OR 0.57, 95% CI 0.31–1.05) and revision due to dislocation (OR 0.14, 95% CI 0.04–0.53). DM implants were associated with a lower incidence of implant dislocation and infection. Functional outcome analysis was limited due to underreporting. No intraprosthetic dislocations were observed. The results suggest that contemporary DM designs may be advantageous in reducing the risk of all-cause revision, revision due to dislocation, and postoperative complication incidence at mid-term follow-up. Further high-quality prospective studies are needed to evaluate the long-term performance of this design, especially in revision cases.
Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England. Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs. In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1. Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology. For any figures or tables, please contact the authors directly.
Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.
Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients. This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures. Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8. This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options.
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 replacement for aseptic loosening. We conducted a cohort study of first-time, single-stage revision hip replacements (RHR) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome. Among 12,676 RHR there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant's first RHR (Hazard Ratio (HR) 1·58 (95%CI 1·16 to 2·15)) and remained significantly elevated for their first 26 cases (HR 1·26 (95%CI 1·00 to 1·58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1·28 (95%CI 1·00 to 1·64)) and 80% greater risk of 90-day mortality (HR 1·81 (95%CI 1·02 to 3·21)) compared to volumes of 20/year. RHR performed at hospitals which had cumulatively undertaken fewer than 168 RHR were at up to 70% greater risk of re-revision (HR 1·70 (95% CI 1·12 to 2·60)), and those having undertaken fewer than 309 RHR were at up to three times greater risk of 90-day mortality (HR 3·06 (95% CI 1·19 to 7·86)). This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHR for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralisation of such cases towards higher-volume units and surgeons.
The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation. With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key. This study assesses the validity of the NHFS in predicting mortality after fragility DFFs. A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases. Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded. All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT. Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk. 285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes. 30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively. Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714). The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF.
The number of revision total hip arthroplasties (THA) is increasing. This procedure is associated with a higher complication rate than primary THA, and so it is important for patients to have realistic expectations. The aim of this systematic review was to gather and summarise the available evidence on patients’ expectations following revision THA. A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar and Web of Science from inception to December 2021. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies. The search strategy generated 3132 references of which 4 articles met the inclusion criteria. Methodological quality scores ranged from 7–10. Patients have high expectations concerning future walking ability, pain and implant longevity. Implant longevity expectations vary according to the longevity of the primary implant. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction (r = .46 – .47). Only one study assessed fulfilment of patient expectations. Great variability was seen in operationalisation and assessment of expectations. Patients undergoing revision THA appear to have high expectations with regards to future outcomes. Whilst results are promising, there is a paucity of high-quality data in this area. Further research is needed, which places emphasis on developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools.
Although total hip arthroplasty (THA) is beneficial for many patients with hip osteoarthritis (OA), a subset of patients experience minimal benefit. It is therefore pertinent to understand the predictors of poor functional outcome to facilitate shared decision making. One such predictor is preoperative radiographic OA severity. The aim of this systematic review was to determine whether preoperative radiographic OA severity could predict postoperative patient-reported outcome measures (PROMs) and satisfaction rates after THA. This systematic review was conducted according to PRISMA guidelines, and the protocol published in PROSPERO (ID:Â CRD42023445918). A literature search was performed using Embase, MEDLINE and Cochrane Library databases. Demographics, radiographic OA severity, PROMs, satisfaction, and complications after THA were collected. A meta-analysis was performed, where appropriate, using a random-effects model. Of 631 identified articles, 12 were included in the final analysis (8,034 participants; mean age 65.2, 38.1% male, mean BMI 29.1 kg/m2). There were three key findings. Firstly, those with mild OA are less likely to achieve a meaningful clinical improvement in PROMs (odds ratio (OR) 0.50, 95% confidence interval (CI) 0.38, 0.65; p < 0.00001). Secondly, two studies indicates that postoperative patient satisfaction was lower in participants with mild OA. Thirdly, participants with mild arthritis experience less improvement in SF-36 physical functioning (mean difference (MD) -8.31, 95% CI -10.97, -5.64; p < 0.00001) and role physical (MD -5.59, 95% CI -8.40, -2.77; p < 0.0001), but showed higher improvement in general health (MD 1.68, 95% CI 0.31, 3.06; p = 0.02). Patients with mild OA, as determined radiographically, are less likely to achieve meaningful clinical improvements in PROMs and have lower postoperative satisfaction after THA. This information will improve collaborative decision-making in the preoperative period.
Current estimates of periprosthetic fracture risk associated with femoral implants is mostly limited to revision only estimates and does not accurately represent stem performance. The aim of this study was to estimate the risk of surgically treated post-operative periprosthetic femoral fracture (POPFF) more accurately associated with frequently used femoral implants used for total hip arthroplasty (THA). A cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020. Periprosthetic fractures were identified from prospectively collected revision records and national procedure coding records. Survival modelling was used to estimate POPFF incidence rates, adjusting for potential confounders. Subgroup analyses were performed for patients over 70 years, with non-osteoarthritic indications, and neck of femur fracture. POPFF occurred in 0.6% (5100/809,832) of cases during a median (IQR) follow up of 6.5 (3.9 to 9.6) years. The majority of POPFF were treated with fixation after implantation of a cemented stem. Adjusted patient time incidence rates (PTIR) for POPFF varied by stem design, regardless of cement fixation. Cemented composite beam stems (CB stems) demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF versus the current gold standard polished taper slip cemented stem. POPFF account for a quarter of all revisions following primary THA. Cemented CB stems are associated with the lowest POPFF risk. Stem design is strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when recommending femoral implants in those most at risk of POPFF.
Given the prolonged waits for hip arthroplasty seen across the U.K. it is important that we optimise priority systems to account for potential disparities in patient circumstances and impact. We set out to achieve this through a two-stage approach. This included a Delphi-study of patient and surgeon preferences to determine what should be considered when determining patient priority, followed by a Discrete Choice Experiment (DCE) to decide relative weighting of included attributes. The study was conducted according to the published protocol ([ For the Delphi study there were 43 responses in the first round, with a subsequent 91% participation rate. Final consensus inclusion was achieved for Pain; Mobility/Function; Activities of Daily Living; Inability to Work/Care; Length of Time Waited; Radiological Severity and Mental Wellbeing. 70 individuals subsequently contributed to the DCE, with radiological severity being the most significant factor (Coefficient 2.27 \[SD 0.31\], p<0.001), followed by pain (Coefficient 1.08 \[SD 0.13\], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 \[SD 0.02\], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months. These results present a new method of determining comparative priority for those on primary hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required.
Adult hip dysplasia AHD is a complex 3D pathology of lateral coverage, version and/or volume and is often associated with increased femoral anteversion. The Mckibbin index MI is the combination of acetabular version AV and femoral version FV and is used as a measure of anterior hip Stability/ Impingement(1). The Bernese Periacetabular osteotomy PAO is a powerful tool in treating AHD, but it does not address FV. De-rotational femoral osteotomies FO increases risk of complications, operative time and might condemn the patient to Secondary osteotomies to balance the gait. We aim to investigate the effect of MI and FV on PROMs in patients undergoing PAO only. 593 PAOs identified on the Local Hip preservation registry between 01/2013 and 7/2023. PAOs for retroversion, residual Perthes and those combined with FO were excluded. Patients with no available PROMS at 2 years were excluded. Independent variables were collected from E-notes and imaging including MI and FV. A multiple linear regression analysis was performed against preoperative iHot12, and iHot12 change at 2years. The mean FV was 18.86± 12.4 SD. Mean MI was 36.07, SD 15.36. Mean preop iHot12 score was 29.83 ± 17.38 SD. Mean change in iHot12 at 2 years was+36.47 ± 28.44 SD. Females and a higher BMI were statistically correlated to a lower preoperative iHot12. A lower preop iHot12 score and a higher preop AI were correlated to a bigger change in iHot12 at 2years with statistical significance. MI and FV were not found to have a statistically significant correlation with Outcome measures, An increased Mckibbin index and femoral anteversion were not correlated with worse outcomes at two years. PAO alone in the presence of increased femoral anteversion avoids risks associated with FO which can be performed later if required.
Total hip replacement (THR) is one of the most common and cost-effective elective surgical procedures. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of locally negotiated prices. This study aims to estimate the total burden of elective THR to the NHS, expenditure on implants, and different scenarios of cost changes if implant selection changed for different patient groups. Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision THR in the 10-year period 2008–2017 and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants. The NHS spent over £4.76 billion performing 702,381 THRs between 2008–2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low. The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice. The HIPPY programme will be conducting practice surveys, discrete choice experiments and a large randomised controlled trial of cemented, uncemented and hybrid fixation in THR for patients under 70 to answer uncertainties.
