Aims. Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Methods. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Results. Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Conclusion. Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391

The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome. Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score. Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001). Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively

Young patients undergoing THA or hip used. HOS and iHOT33 have demonstrated to be useful in hip preservation surgery but never used in THA. The aim of the study was to evaluate long-term clinical outcomes with HOS and iHOT33 in hip arthroscopy and THA. We conducted a retrospective study with prospective data collection of 118 consecutive young patients (<65 y.o.) between 2008 to 2012 who underwent hip arthroscopy or THA. The mean follow-up was 12.05 years. All surgeries were done by the same senior surgeon. PROMs used were iHOT-33 and HOS preoperatively, at one year and 10 years. SPSS Statistics Grad Pack 28.0 software was used for statistical analysis. Arthroscopy Group (57 patients): Mean age 35.36 years. 55.93% were male. iHOT33 mean differential improvement was 24.43 at 1 year, 70,17% exceed MCID and 49,1% SCB. HOS mean differential improvement was 16.26 at one year. 54,38 % patients exceed MCID and 49,36% SCB. At 10 years, iHOT33 mean differential improvement was 14,36 and 12.56 for HOS. Regarding complications, 3 patients underwent THA (5.26%) and 10 (17.54%) continued with groin pain. THA Group (61 patients): Mean age 52,54 years. 55.73% were male. Cementless THA was used in all patients with ceramic on ceramic used in 77%. iHOT33 mean differential improvement was 41,57 at 1 year. 95,08% patients exceed MCID and 85,25% SCB. HOS mean differential improvement was 16.57 points at one year. 85,25% patients exceed MCID and 81,97% SCB. At 10 years, iHOT33 mean differential improvement was 20,15 and 14.12 for HOS. Regarding complications, 1 patient underwent DAIR for infection (1.64%) and 1 dislocation with close reduction (1.64%). iHOT33 or HOS scores should be considered to be used in young active patients after hip preserving surgery or THA, with more predictable results at long-term in THA group

Aims. The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

The challenges faced by hip surgeons have changed over the last decade. Historically, fixation, polyethylene wear, osteolysis, loosening and failure to osseointegrate dominated the discussions at hip surgery meetings. With the introduction of highly crosslinked polyethylene, wear and osteolysis are currently not significant issues. Improved surgical technique has resulted in a high rate of osseointegration and once fixed, loosening of cementless components is rare. In this session, we will focus on issues that orthopaedic surgeons performing hip surgery routinely face including bearing couples in the young active patient, implant choices in the dysplastic hip and osteoporotic femur, evaluation and management of the unstable hip and differential diagnosis of the painful THR

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes. Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection. The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window. Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure. On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig). This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry

An international faculty of orthopaedic surgeons presented their work on the current challenges in hip surgery at the London Hip Meeting which was attended by over 400 delegates. The topics covered included femoroacetabular impingement, thromboembolic phenomena associated with hip surgery, bearing surfaces (including metal-on-metal articulations), outcomes of hip replacement surgery and revision hip replacement. We present a concise report of the current opinions on hip surgery from this meeting with appropriate references to the current literature

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy.

55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used.

As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible.

Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time.

Fracture of contemporary femoral stems is a rare occurrence. Earlier THR stems failed due to design issues or post manufacturing heat treatments that weakened the core metal. Our group identified and analyzed 4 contemporary fractured femoral stems after revision surgery in which electrochemical welds contributed to the failure.

All four stems were proximally porous coated titanium alloy components. All failures occurred in the neck region post revision surgery in an acetabular cup exchange. All were men and obese. The fractures occurred at an average of 3.6 years post THR redo (range, 1.0–6.5 years) and 8.3 years post index surgery (range, 5.5–12.0 years). To demonstrate the effect of electrocautery on retained femoral stems following revision surgery, we applied intermittent electrosurgical currents at three intensities (30, 60, 90 watts) to the polished neck surface of a titanium alloy stem under dry conditions.

At all power settings, visible discoloration and damage to the polished neck surface was observed. The localized patterns and altered metal surface features exhibited were like the electrosurgically-induced damage priorly reported.

The neck regions of all components studied displayed extensive mechanical and/or electrocautery damage in the area of fracture initiation. The use of mechanical instruments and electrocautery was documented to remove tissues in all 4 cases.

The combination of mechanical and electrocautery damage to the femoral neck and stem served as an initiation point and stress riser for subsequent fractures. The electrocautery and mechanical damage across the fracture site observed occurred iatrogenically during revision surgery. The notch effect, particularly in titanium alloys, due to mechanical and/or electrocautery damage, further reduced the fatigue strength at the fractured femoral necks. While electrocautery and mechanical dissection is often required during revision THA, these failures highlight the need for caution during this step of the procedure in cases where the femoral stem is retained.

The challenges faced by hip surgeons have changed over the last decade. Historically, fixation, polyethylene wear, osteolysis, loosening and failure to osseointegrate dominated the discussions at hip surgery meetings. With the introduction of highly crosslinked polyethylene, wear and osteolysis are currently not significant issues. Improved surgical technique has resulted in a high rate of osseointegration and once fixed, loosening of cementless components is rare. In this section, we will focus on issues that orthopaedic surgeons performing hip surgery routinely face including bearing couples in the young active patient, implant choices in the dysplastic hip and osteoporotic femur, evaluation and management of the unstable hip and differential diagnosis of the painful THR

The disadvantages of hip spica casts following hip surgery for cerebral palsy include fractures, plaster sores, soiling and general inconvenience. In this series, 56 hips in 31 children aged 4 to 16 years (mean 8) were treated for hip displacement in keeping with the recommendations of others (eg Miller et al 1997) between 2005 and 2008 by one consultant. There were 29 open reductions for a Reimer's migration index (RMI) greater than 50%. A blade plate was used for the femoral osteotomy, and an acetabuloplasty was performed for 22 hips. No casting or immobilisation of any sort was used. The average length of stay was 5 days. The results at 5 the year follow-up were chosen so that all patients were at the same stage. The average RMI pre-operatively for displaced hips was 76.9 +/− 21.3. At follow-up it was 18.8 +/− 19.7. 18 patients had pain prior to hip surgery; 6 had pain during follow-up, and 4 of these responded to removal of metal; and one required a proximal femoral resection. There were 3 complications: one re-dislocation in the immediate post-operative period, one mal-union because the blade plate cut out; and one of the three walking children fractured below the blade plate 2 ½ months after surgery. There were no infections. The radiographic and clinical outcomes of hip reconstruction without hip spica immobilisation are good, reproducible and long-lasting. The child may be nursed free post-operatively and discharged in his or her own chair. As a result of studying these patients, since 2009 we have introduced locking plates for better fixation, and pre- and post-operative Paediatric Pain Profiles and CPCHILD questionnaires

Objective of the study is to determine to what extent patients experience more limitations 1–5 years after revision total hip arthroplasty (THA) compared to patients after primary THA, and if this is accompanied by a reduction in physical activity behavior. Five hundred and six patients were included: 372 primary and 134 revision THA. Questionnaires were used to measure limitations and physical activity. Linear regression analysis showed that patients after revision surgery report significantly more, clinically relevant limitations compared with primary THA patients, but did not show a significant difference in mean total minutes of physical activity per week. Physical activity behavior appeared to be similar for primary and revision THA patients. The results stress the importance of determining different aspects of recovery after THA.

The aim of this study is to evaluate which patients, if any, can be eligible for a rapid discharge from Hip Surgery Department at 24 hours after primary total hip arthroplasty. Methods In this retrospective clinical trial were included all patients undergone to primary total hip arthroplasty in our Hip Surgery Department from January to June 2004. Exclusion criteria were preoperative anaemia (Hb< 12g/dL), coagulation disease, hip fracture, previous hip surgery and not-weight bearing indication after operation. All patients received an uncemented total hip arthroplasty with posterior surgical approach in regional anaesthesia. All patients had the same post-operative (PO) management including analgesia, prevention of DVT, immediate muscle exercises and physiotherapy for walking on crutches starting on the second PO day. The clinical history, vital parameters, haemoglobin (Hb) value before surgery and for 5 days PO, adverse events like luxation and transfusion were registered. For the statistical evaluation were used the paired “t-test” with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant. Results 234 patients (mean age 65y; range 21–91y) were admitted to the study. 128 women and 106 men. For the blood loss evaluation, the presence of no homogeneous preoperative Hb lead us to analyse the decrease rate of preoperative Hb (DRPH). The mean DRPH was: 22,47% at 1dayPO; 25,09% at 2 daysPO; 22,83% at 3 daysPO; 26,76% at 5 daysPO. For the safety evaluation were considered the incidence of transfusions (limit was set at Hb< 8g/dL) that were related to the preoperative Hb and the age. The transfusion incidence for each preoperative Hb (PrHb) value was: 14% (7/49) for 12< PrHb< 13; 11% (6/53) for 13< PrHb< 14; 11% (5/43) for 14< PrHb< 15; 7% (2/26) for 15< PrHb< 16g/dL. For age under 70y and PrHb> 14g/dL there were the lowest transfusion incidence: 3% (2/41). No adverse events were able to prevent patients from going to Rehabilitation Unit. All patients were able to do their own physiotherapical programme. Pain during physiotherapy was low (mean value of VAS = 3,47). Discussion During the last decade the improvement of anaesthesiologic and surgical technique with minimally invasive soft tissue approach (small incision and little muscular sacrifice) lead to a significant reduction in adverse events after primary total hip arthroplasty. So the relative safety of this surgery justifies the growing importance of intensive rehabilitation and fast recovery. This study shows the safety of a rapid discharge from the Hip Surgery Department. The main adverse event after 24 hours PO is the necessity of blood transfusions, but the incidence rate of only 3%, like in patients with preoperative Hb> 14g/dL and age below 70 years, is not a problem for the physicians of the Rehabilitation Unit. Conclusion This study confirms the possibility to perform a safe One Day Hip Surgery by an accurate selection of the patient

Peripheral nerve injury is an uncommon but serious complication of hip surgery that can adversely affect the outcome. Several studies have described the use of electromyography and intra-operative sensory evoked potentials for early warning of nerve injury. We assessed the results of multimodal intra-operative monitoring during complex hip surgery. We retrospectively analysed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intra-operative monitoring from a total pool of 7894 patients who underwent hip surgery during this period. In 24 (35%) procedures the surgeon was alerted to a possible lesion to the sciatic and/or femoral nerve. Alerts were observed most frequently during peri-acetabular osteotomy. The surgeon adapted his approach based on interpretation of the neurophysiological changes. From 69 monitored surgical procedures, there was only one true positive case of post-operative nerve injury. There were no false positives or false negatives, and the remaining 68 cases were all true negative. The sensitivity for predicting post-operative nerve injury was 100% and the specificity 100%. We conclude that it is possible and appropriate to use this method during complex hip surgery and it is effective for alerting the surgeon to the possibility of nerve injury

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d’Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone. The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d’Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region. Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results. Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year. Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?

Introduction: Revision hip surgery with impaction allografting is an attractive operation because of its potential to restore lost bone stock. Several authors have reported variable results, some disastrous, with massive subsidence of the stem. Aim: To study the radiographic and clinical results of impaction allografting for revision hip surgery done in our department. Materials and methods: 49 patients (50 hips) underwent revision hip surgery using the impaction allografting technique and the Exeter stem between the years 1993 to 1997. The average follow up was 6 years (range 4 – 9 years). Results: There were 7 dislocations. One patient had early painful subsidence of the stem requiring revision. 44 (90%) hips had subsidence of stem equal to or less than 5 mm at last follow up. 5 (10%) had subsidence ranging from 6 to 7 mm. Hip function was uniformly good and patients were extremely satisfied. Conclusion: Revision hip surgery with impaction allografting is an effective operation. With meticulous attention to this technique, revision hip surgery need not necessarily be associated with inferior outcomes compared to primary hip surgery

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Significant proximal femoral bone deficiency in revision hip surgery poses a considerable challenge, especially as revision hip surgery is increasing in prevalence. Many femoral prosthetic devices, which compensate for this bone loss, are available to surgeons but ideally one wants to restore viable proximal bone stock. The Oxford Universal Hip (OUH) has been designed and modified with these challenges in mind. This is atrimodular, non-locking device that allows for some rotation and subsidence in the cement. Load transfer occurs at the proximal wedge, thus avoiding proximal stress shielding. The OUH has been used extensively in both primary and revision hip surgery and is particularly useful when used in conjunction with proximal impaction bone grafting. The main aim of this study was to determine the clinical outcome of the patients. The viability and survivorship of the impacted bone graft was assessed in order to give some indication of adequate perfusion of the incorporated bone grafting. Between 1999 and 2002 the OUH, in combination with proximal impaction bone grafting, was implanted in 72 hip revisions in 69 patients. All patients were clinically evaluated using the Oxford Hip score. Histological samples of impacted bone grafting were analysed by a pathologist 2 years after implantation to assess viability and perfusion of the impacted bone graft. The Oxford Hip Score improved from a pre-operative to a post-operative score of 45 (26–58) to 24.3 (12–43) respectively (p< 0.001). The mean follow up time was 32.7 months and in that time there were no re-revisions for aseptic loosening. Histology demonstrated viable bone stock in the proximal femur where bone grafting had been impacted 2 years previously. The OUH is a versatile hip prosthesis for use in revision hip arthroplasty and is especially well suited to proximal impaction bone grafting where it is possible to restore viable bone stock

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England. The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action. A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed. The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465. Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims