Aims. The gluteus minimus (GMin) and gluteus medius (GMed) have unique structural and functional segments that may be affected to varying degrees, by end-stage osteoarthritis (OA) and normal ageing. We used data from patients with end-stage OA and matched healthy controls to 1) quantify the atrophy of the GMin and GMed in the two groups and 2) describe the distinct patterns of the fatty infiltration in the different segments of the GMin and GMed in the two groups. Methods. A total of 39 patients with end-stage OA and 12 age- and sex frequency-matched healthy controls were prospectively enrolled in the study. Fatty infiltration within the different segments of the GMin and the GMed was assessed on MRI according to the semiquantitative classification system of Goutallier and normalized cross-sectional areas were measured. Results. The GMin was smaller in the OA-group (p < 0.001) compared to the control group, but there was no group difference in the size of the GMed (p = 0.101). Higher levels of fatty infiltration were identified in the anterior segment of the GMin (p = 0.006) and the anterior (p = 0.006) and middle (p = 0.047) segments of the GMed in the OA group. All subjects in the control group had fatty infiltration of the anterior segment of the GMin, but all except one had no fatty infiltration in the entire GMed. Conclusion. End-stage OA was associated with significant atrophy of the GMin and higher levels of fatty infiltration, particularly in the anterior segments of the GMin and GMed. Minor fatty infiltration of the anterior segment of GMin appears to be a normal part of ageing. Our study has demonstrated different patterns of atrophy and fatty infiltration between patients with end-stage OA and healthy matched peers. Cite this article: Bone Jt Open 2021;2(1):40–47

There is some evidence to suggest that outcomes of THA in patients with minimal radiographic osteoarthritis may not be associated with predictable outcomes. The aim of this study was to:. Assess the outcome of patients with hip pain who underwent THA with no or minimal radiographic signs of osteoarthritis,. Identify patient comorbidities and multiplanar imaging findings which are predictive of outcome,. Compare the outcome in these patients to the expected outcome of THA in hip OA. A retrospective review of 107 hips (102 patients, 90F:12M, median age 40.6, IQR 35.1–45.8 years, range 18–73) were included for analysis. Plain radiographs were evaluated using the Tonnis grading scale of hip OA. Outcome measures were all-cause revision; iHOT12; EQ-5D; Oxford Hip Score; UCLA Activity Scale; and whether THA had resulted in the patient's hip pain and function being Better/Same/Worse. The median Oxford Hip Score was 33.3 (IQR 13.9, range 13–48), and 36/107 (33.6%) hips achieved an OHS≥42. There was no association between primary hip diagnosis and post-operative PROMs. A total of 91 of the 102 patients (89.2%, 93 hips) reported that their hip pain and function was Better than prior to THA and would have the surgery again, 7 patients (6.8%, 10 hips) felt the Same, and 4 patients (3.9%, 4 hips) felt Worse and would not have the surgery again. Younger patients undergoing total hip arthroplasty with no or minimal radiographic osteoarthritis had lower postoperative Oxford Hip Scores than the general population; though most felt symptomatically better and knowing what they know now, would have surgery again. Those with chronic pain syndrome or hypermobility were likely to benefit less. Those with subchondral cysts or joint space narrowing on CT imaging were more likely to achieve higher functional scores and satisfaction

An intra-articular steroid injection can be a useful diagnostic tool in patients presenting with debilitating hip pain and radiographically mild osteoarthritis. The clinical and patient reported outcomes associated with patients who have radiographically mild osteoarthritis and undergo total hip arthroplasty (THA) remain poorly studied. Patients undergoing primary, elective THA at a single academic medical center by a fellowship-trained adult reconstruction surgeon between 2017–2023 were identified. Only those patients who underwent an intra-articular corticosteroid injection into the operative hip within one year of surgery were included. Patients were divided into two cohorts based on the severity of their osteoarthritis as determined by preoperative radiographs; those with Kellgren-Lawrence (KL) grade I-II arthritis were classified as “mild” whereas those with KL grade III-IV arthritis were classified as “severe”. Clinical and patient reported outcomes at final follow-up were compared between cohorts. The final cohorts included 25 and 224 patients with radiographically mild and severe osteoarthritis, respectively. There were no baseline differences in age, gender or time between intra-articular corticosteroid injection and THA between cohorts. There were no significant differences in the preoperative or postoperative HOOS JR values between patients with mild or severe arthritis (all p>0.05). There were no significant differences in the change in HOOS JR scores from the preoperative to final follow-up timepoints between cohorts. There were no significant differences in the percentage of patients who achieved the minimal clinically important difference (MCID) on the HOOS JR questionnaire between cohorts. Patients with radiographically mild osteoarthritis who feel relief of their hip pain following an intra-articular corticosteroid injection report similar preoperative debility and demonstrate similar improvements in patient reported outcome scores following THA compared to patients with radiographically severe osteoarthritis

Aims. Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA. Methods. A total of 50 patients from the Danish Pain Research Biobank (DANPAIN-Biobank) between January and June 2018 were included. Postoperative outcome was assessed as change in Oxford Hip Score (OHS) from baseline to 12 months after THA, pain was assessed on a numerical rating scale, and disability using the Pain Disability Index. Multiple regression models for each clinical outcome were included for biomarkers in blood and CSF, respectively, including age, sex, BMI, and Kellgren-Lawrence score. Results. Change in OHS was associated with blood concentrations of tumour necrosis factor (TNF), interleukin-8 (IL-8), interleukin-6 receptor (IL-6R), glycoprotein 130 (gp130), and IL-1β (R. 2. = 0.28, p = 0.006), but not with CSF biomarkers. Baseline pain was associated with blood concentrations of lymphotoxin alpha (LTα), TNFR1, TNFR2, and IL-6R (R. 2. = 0.37, p < 0.001) and CSF concentrations of TNFR1, TNFR2, IL-6, IL-6R, and IL-1Ra (R. 2. = 0.40, p = 0.001). Baseline disability was associated with blood concentrations of TNF, LTα, IL-8, IL-6, and IL-1α (R. 2. = 0.53, p < 0.001) and CSF concentrations of gp130, TNF, and IL-1β (R. 2. = 0.26, p = 0.002). Thus, preoperative systemic low-grade inflammation predicted 12-month postoperative outcome after THA, and was associated with preoperative pain and disability. Conclusion. This study highlights the importance of systemic inflammation in osteoarthritis, and presents a possible path for better patient selection for THA in the future. Preoperative central neuroinflammation was associated with preoperative pain and disability, but not change in OHS after THA. Cite this article: Bone Joint Res 2024;13(12):741–749

Aims. This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry. Methods. In total, 116 patients who underwent unilateral total hip arthroplasty were included in this study. Of these, 93 had DDH-OA and 23 had PHOA. Patients with DDH-OA were categorized into three groups: Crowe grade I, II/III, and IV. Anatomical femoral length, femoral length greater trochanter (GT), femoral length lesser trochanter (LT), tibial length, foot height, lower LL, and whole LL were evaluated using preoperative CT data of the whole leg in the supine position. Asymmetry was evaluated in the Crowe I, II/III, IV, and PHOA groups. Results. The incidences of whole and lower LL asymmetries were 40%, 62.5%, 66.7%, and 26.1%, and 21.7%, 20.8%, 55.6%, and 8.7% in the Crowe I, II/III, and IV, and PHOA groups, respectively. The incidence of tibial length asymmetry was significantly higher in the Crowe IV group (44.4%) than that in the PHOA group (4.4%). In all, 50% of patients with DDH-OA with femoral length GT and LT asymmetries had lower LL asymmetry, and 75% had whole LL asymmetry. The incidences of lower and whole LL asymmetries were 20% and 42.9%, respectively, even in the absence of femoral length GT and LT asymmetries. Conclusion. Overall, 43% of patients with unilateral DDH-OA without femoral length asymmetry had whole LL asymmetry of ≥ 5 mm. Thus, both the femur length and whole LL should be measured to accurately assess LL discrepancy in patients with unilateral DDH-OA. Cite this article: Bone Jt Open 2024;5(2):79–86

Aims. The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia. Methods. We reviewed patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia who underwent TOA between November 1998 and December 2019. Patient demographic details, osteotomy-related complications, and the modified Harris Hip Score (mHHS) were obtained via medical notes review. Radiological indicators of hip dysplasia were assessed using preoperative and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors of failure. Results. This study included 127 patients (137 hips). Median follow-up period was ten years (IQR 6 to 15). The median mHHS improved from 59 (IQR 52 to 70) preoperatively to 90 (IQR 73 to 96) at the latest follow-up (p < 0.001). The survival rate was 90% (95% CI 82 to 95) at ten years, decreasing to 21% (95% CI 7 to 48) at 20 years. Fair joint congruity on preoperative hip abduction radiographs and a decreased postoperative anterior wall index (AWI) were identified as independent risk factors for failure. The survival rate for the 42 hips with good preoperative joint congruity and a postoperative AWI ≥ 0.30 was 100% at ten years, and remained at 83% (95% CI 38 to 98) at 20 years. Conclusion. Although the overall clinical outcomes of TOA in patients with advanced osteoarthritis are suboptimal, favourable results can be achieved in selected cases with good preoperative joint congruity and adequate postoperative anterior acetabular coverage. Cite this article: Bone Joint J 2024;106-B(8):783–791

We determined the association between frailty and 30-day mortality following total hip arthroplasty (THA) and the impact of THA on 30-day mortality compared to a control population. We used primary care data (Clinical Practice Research Datalink), linked secondary care data (Hospital Episode Statistics) and Office for National Statistics mortality data. Frailty was assessed using a validated frailty index based on coded data in the primary care record and categorised as fit, mild, moderate, and severe frailty. The association between frailty and 30-day mortality following THA due to osteoarthritis was assessed using Cox regression, adjusted for year of birth, sex, quintile of index of multiple deprivation and year of surgery. Mortality following THA was also compared to a control population who had osteoarthritis but no previous THA, matched on year of birth, sex, and quintile of index of multiple deprivation. 103,563 cases who had a THA and their matched controls contributed data. Among those who had THA, compared to fit participants, 30-day mortality increased with increasing frailty; adjusted hazard ratio (HR) (95% CI) among mild frailty, 0.87 (0.66, 1.15); moderate frailty 1.73 (1.26, 2.38); and severe frailty, 2.85 (1.84, 4.39). Compared to fit controls who did not have surgery, 30-day mortality was higher among fit people who had THA, adjusted HR 1.60 (1.15, 2.21). There was, however, no statistically significant difference in 30-day mortality among cases with mild, moderate and severe frailty compared to controls in the same frailty category. Among people who had THA, 30-day mortality increased with increasing frailty. While 30-day mortality was increased among fit individuals who had THA compared to fit controls who did not have surgery, there did not appear to be increased mortality among individuals with mild, moderate or severe frailty compared to controls in the same frailty category. A healthy surgery (selection) effect may have impacted on the comparison of mortality among cases and controls

It is unclear whether patients with early radiographic osteoarthritis (OA) but severe hip symptoms benefit from total hip replacement (THR). We aimed to assess which factors were associated with successful THR in this patient group. From a consecutive series of 1,935 patients undergoing THR we identified 70 (3.6%) patients with early OA (Kellgren and Lawrence (KL) grades 0-2). These were compared with 200 patients with advanced OA (KL grades 3–4). Outcomes were Oxford Hip Scores (OHS), EQ5D and EQ-VAS scores; compared pre-operatively with one year post-operatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THR in the early OA group. Success was defined as reaching a postoperative OHS≥42. The early OA group were significantly younger (61 vs 66 years; P=0.0035). There were no significant differences in body mass index, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% versus 50.4%; P<0.0001) and improvement in EQ5D (0.151 versus 0.002; P<0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, we identified 16/70 (22.9%) patients who had a ‘successful’ THR. Of those with early OA, 38 patients had pre-operative CT or MRI scans. Patients who had a ‘successful’ THR were significantly more likely to have subchondral cysts on CT/MRI (91.7% versus 57.7%; P=0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% versus 38.2%; P=0.0353). The combination of cysts and joint space width (JSW) <1mm was associated with a PoPC of 68%. Plain radiographs were found to significantly underestimate the narrowest JSW compared to CT/MRI (2.4mm versus 1.0mm; P<0.0001). We advise caution in performing THRs in patients with early OA (KL grades 0-2) on plain radiographs. We advocate pre-operative cross-sectional imaging (CT or MRI) in these patients. In the absence of cysts on cross-sectional imaging, a THR seems unlikely to provide a satisfactory outcome

Aims. The aim of this study was to determine whether total hip arthroplasty (THA) for chronic hip pain due to unilateral primary osteoarthritis (OA) has a beneficial effect on cognitive performance. Methods. A prospective cohort study was conducted with 101 patients with end-stage hip OA scheduled for THA (mean age 67.4 years (SD 9.5), 51.5% female (n = 52)). Patients were assessed at baseline as well as after three and months. Primary outcome was cognitive performance measured by d2 Test of Attention at six months, Trail Making Test (TMT), FAS-test, Rivermead Behavioural Memory Test (RBMT; story recall subtest), and Rey-Osterrieth Complex Figure Test (ROCF). The improvement of cognitive performance was analyzed using repeated measures analysis of variance. Results. At six months, there was significant improvement in attention, working speed and concentration (d2-test; p < 0.001), visual construction and visual memory (ROCF; p < 0.001), semantic memory (FAS-test; p = 0.009), verbal episodic memory (RBMT; immediate recall p = 0.023, delayed recall p = 0.026), as well as pain (p < 0.001) with small to large effect sizes. Attention, concentration, and visual as well as verbal episodic memory improved significantly with medium effect sizes over η. 2. partial. = 0.06. In these cognitive domains the within-group difference exceeded the minimum clinically important difference. Conclusion. THA is associated with clinically relevant postoperative improvement in the cognitive functions of attention, concentration, and memory. These data support the concept of a broad interaction of arthroplasty with central nervous system function. Cite this article: Bone Joint J 2022;104-B(3):331–340

To design osteoarthritis (OA) care based on prognosis, we need to identify individuals who are most likely of disease progression. We estimated survival time of the native hip and knee joint and evaluated what patient-related and OA disease-related factors associated with progression to joint replacement surgery. We included 72,069 patients referred to first-line OA intervention (patient education and exercise) during 2008 and 2016 and registered in the Swedish quality register Better Management of Patients with Osteoarthritis (BOA). Kaplan–Meier survival analyses were used to estimate joint survival time. Hazard ratios (HR) with 95% confidence interval [CI] were calculated using multiple Cox regression. The 5-year survival time of the native joint was 56% for hip OA and 80% for knee OA. Disease-related factors were more strongly associated with progression to joint replacement (e.g. willingness for surgery HR; hip 2.9 [95% CI, 2.7–3.1], knee 2.7 [2.6–2.9] and walking difficulties (HR; hip 2.2 [2.0–2.5], knee 1.9 [1.7–2.2]), than patient-related factors such socioeconomic factors (e.g. highest income quartile HR; hip 1.3 [1.2–1.3], knee 1.3 [1.2–1.4]) and comorbidities (e.g. ≥6 conditions HR; hip: 0.7 [0.6–0.7], knee; 1.1 [1.0–1.2]). Patients with hip OA were more likely to undergo surgery and at an earlier time compared with those with knee OA. Progression was strongly influenced by factors associated with the OA disease, but other patient-related factors are important. However, a large proportion of patients with OA do not seem to require surgery, especially among those with knee OA

The aim of this study is the comparative assessment of long term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA. 122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford hip score (OHS), Short form-12 health survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, timed up and go test (TUG), Parker mobility, Lower extremity function score (LEFS) and UCLA scores. At a mean follow up of 14.4 years (10 to 20) a cumulative success rate of 96% (95% CI 96 to 99%) in Group A and 98% (95% CI 97 to 99%) in Group B with operation for any reason as an end point was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U test, p= 0.014), OHS (Mann-Whitney U test, p= 0.020) and physical component of SF-12 scores (Mann-Whitney U test, p= 0.029) only. In Group A, in multiple regression analysis, patients’ cognition (p=0.001), BMI (p=0.007) and pain (p=0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p=0.03) was found to influence quality of life (EQ-5D-5). In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes

Aims. Rotational acetabular osteotomy (RAO) has been reported to be effective in improving symptoms and preventing osteoarthritis (OA) progression in patients with mild to severe develomental dysplasia of the hip (DDH). However, some patients develop secondary OA even when the preoperative joint space is normal; determining who will progress to OA is difficult. We evaluated whether the preoperative cartilage condition may predict OA progression following surgery using T2 mapping MRI. Methods. We reviewed 61 hips with early-stage OA in 61 patients who underwent RAO for DDH. They underwent preoperative and five-year postoperative radiological analysis of the hip. Those with a joint space narrowing of more than 1 mm were considered to have 'OA progression'. Preoperative assessment of articular cartilage was also performed using 3T MRI with the T2 mapping technique. The region of interest was defined as the weightbearing portion of the acetabulum and femoral head. Results. There were 16 patients with postoperative OA progression. The T2 values of the centre to the anterolateral region of the acetabulum and femoral head in the OA progression cases were significantly higher than those in patients without OA progression. The preoperative T2 values in those regions were positively correlated with the narrowed joint space width. The receiver operating characteristic analysis revealed that the T2 value of the central portion in the acetabulum provided excellent discrimination, with OA progression patients having an area under the curve of 0.858. Furthermore, logistic regression analysis showed T2 values of the centre to the acetabulum’s anterolateral portion as independent predictors of subsequent OA progression (p < 0.001). Conclusion. This was the first study to evaluate the relationship between intra-articular degeneration using T2 mapping MRI and postoperative OA progression. Our findings suggest that preoperative T2 values of the hip can be better prognostic factors for OA progression than radiological measures following RAO. Cite this article: Bone Joint J 2021;103-B(9):1472–1478

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Introduction. Despite evidence-based recommendations opioids and benzodiazepines are commonly prescribed to treat osteoarthritis. This study aims to quantify the prevalence of opioid and benzodiazepine prescriptions given for the primary diagnosis of osteoarthritis across a large healthcare system. Additionally, we aim to characterize risk factors for drug misuse, abuse, and diversion. Methods. We conducted a descriptive analysis of adult patient encounters with a primary diagnosis of osteoarthritis during a one-year time period from Jan –Dec 2016 at a large, healthcare system. Demographic data, prescription data, patient-specific prescription drug use risk criteria were collected. Descriptive analysis was conducted to characterize the population of arthritis patients who received prescription opioids. The rate of controlled substance prescribing was calculated for the population as a whole and among subgroups (age, facility type, and patient risk profile). Results. During the one-year time frame, our system had 45,341 outpatient encounters with a primary diagnosis of osteoarthritis. Almost a third of these encounters resulted in a prescription for an opioid or benzodiazepine (n = 7,375; 31.9%). The majority of patients were between ages 18 and 64 (57.1%), with 42.9% patients >65. While 38.8% were prescribed in an acute care setting (ED or Urgent Care), the majority were in outpatient clinics (58.8%) with 36.2 % of outpatient encounters originating from orthopaedic clinics. 14.3% of those who received a prescription had a risk factor for prescription misuse, the most prevalent being “early refill” (7.0%). Conclusion. Opioids remain a prevalent treatment for osteoarthritis, given in over a third of encounters. These prescriptions pose a risk for adverse outcomes, since over a third of patients had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis

Introduction. Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNF), especially in physiologically younger patients. While elective THA for primary osteoarthritis (OA) has demonstrated low rates of complications and readmissions, the outcomes of THA for FNF are less predictable. Additionally, these THA procedures are equally included in various alternative payment bundles. Therefore, the aim of this study is to assess postoperative complication rates after THA for primary OA compared with FNF. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2008 to 2016 was queried. Patients were identified using the Current Procedural Terminology (CPT) code for THA (27130) and divided into groups by diagnosis; OA in one group and FNF in another. Univariate statistics were performed. T-test compared continuous variables between groups, and Chi-square test compared categorical variables. Multivariate and propensity matched logistic regression analyses were performed to control for risk factors of interest. The primary outcomes for this study were death or serious morbidity (surgical site infection (SSI), infection, respiratory complication, cardiac complication, sepsis, or blood loss anemia requiring postoperative transfusion). Additional secondary outcomes included the incidence of specific complications, total operative time (time from incision to closure), length of hospital stay and proportion of patients that were discharged home. Results. Analyses included 139,635 patients undergoing THA. OA was the indication in 135,013 cases and FNF in 4,622 cases. Unadjusted analysis showed a significantly higher rate of mortality when THA was done for hip fracture (2.1% vs. 0.1%; p<0.001). There was also a significantly increased rate of serious morbidity for hip fracture patients; including cardiac complications (3.5% vs 0.96%; p<0.001), respiratory complications (1.3% vs 0.2%; p<0.001), postop transfusion (23.1% vs 9.36%; p<0.001), sepsis (0.95% vs 0.3%; p<0.001). There was a significantly higher percentage of patients requiring reoperation (4.5% vs 2.0%; p<0.001) and readmission (8.0% vs 3.5%; p<0.001) in the hip fracture group. There was a significantly higher percentage of patients in the hip fracture groups having operative time >90min (16.4% vs 10.1%; p<0.001), length of stay longer than 5 days (53.8% vs 7.5%; p<0.001), and a significantly lower percentage of patients who were discharged home (39.0% vs 78.0%; p<0.001). Propensity score matching resulted in a cohort of 6,968 patients; 3,484 in both the hip fracture and osteoarthritis groups. Mortality within 30 days was 530% higher, and major morbidity was 36% higher among FNF patients. Reoperation was 40% higher, readmission was 36% higher, operative length at the 90th percentile was 74% higher, prolonged length of stay was 838% higher, and discharge to home was 62% lower for the FNF group compared with OA patients. Logistic, reverse stepwise regression model () results were consistent with the propensity-matched analysis. Discussion and Conclusion. This large database study showed a higher risk of postoperative complications including mortality, major morbidity, reoperation, readmission, prolonged operative time, increased length of stay, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. Without risk adjustment, the bundled payment methods that are applied to THA procedures including those performed for FNF are at a disadvantage and likely inadequate to cover the more costly episode of care related to treating hip fracture patients

Although the association between femoroacetabular impingement and osteoarthritis is established, it is not yet clear which hips have the greatest likelihood to progress rapidly to end-stage disease. We investigated the effect of several radiological parameters, each indicative of a structural aspect of the hip joint, on the progression of osteoarthritis. Pairs of plain anteroposterior pelvic radiographs, taken at least ten years apart, of 43 patients (43 hips) with a pistol-grip deformity of the femur and mild (Tönnis grade 1) or moderate (Tönnis grade 2) osteoarthritis were reviewed. Of the 43 hips, 28 showed evidence of progression of osteoarthritis. There was no significant difference in the prevalence of progression between hips with initial Tönnis grade 1 or grade 2 osteoarthritis (p = 0.31). Comparison of the hips with and without progression of arthritis revealed a significant difference in the mean medial proximal femoral angle (81° vs 87°, p = 0.004) and the presence of the posterior wall sign (39% vs 7%, p = 0.02) only. A logistic regression model was constructed to predict the influence of these two variables in the development of osteoarthritis. Mild to moderate osteoarthritis in hips with a pistol-grip deformity will not progress rapidly in all patients. In one-third, progression will take more than ten years to manifest, if ever. The individual geometry of the proximal femur and acetabulum partly influences this phenomenon. A hip with cam impingement is not always destined for end-stage arthritic degeneration

Since the introduction of national guidelines in 2009 encouraging the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures there has been no population-based studies into the surgical outcomes for this indication. This study aims to calculate the complication rates for THA when performed for a fractured neck of femur and compare them to THA performed for primary osteoarthritis in the same population. The Scottish Arthroplasty Project was used to identify all THAs performed in Scotland for neck of femur fracture and osteoarthritis between 1st of January 2009 and 31st December 2014. Dislocation, infection and revision rates at 1 year were calculated. The rate of dislocation, infection and revision at 1 year were all significantly increased among the fracture neck of femur cohort. In total 44046 THAs were performed, 38316 for OA and 2715 for a neck of femur fracture. 2.1% of patients (n=57) who underwent a THA for a neck of femur fracture suffered a dislocation in the 1st year postoperatively, compared to 0.9% (n=337) when the THA was performed for osteoarthritis. Relative Risk of dislocation: 2.3870 (95% C.I. 1.8077–3.1252, p value <0.0001). Relative Risk of infection: 1.4561 (95% C.I. 1.0496–2.0200, p value 0.0245) Relative Risk of revision: 1.4807 (95% C.I. 1.0308–2.1268, p value 0.0336). This is the first time a dislocation rate for THA performed for a neck of femur fracture has been calculated for an entire population. As the number of THAs for neck of femur fracture increases this dislocation rate will have clinical implications

Due to limitations of existing pharmacological therapies for the management of chronic pain in osteoarthritis (OA), surgical interventions remain a major component of current standard of care, with total joint replacements (TJRs) considered for people who have not responded adequately to conservative treatment. This study aimed to quantify the economic burden of moderate-to-severe chronic pain in patients with OA in England prior to TJR. A retrospective, longitudinal cohort design was employed using Clinical Practice Research Datalink GOLD primary care data linked to Hospital Episode Statistics secondary care data in England. Patients (age ≥18 years) with an existing OA diagnosis of any anatomical site (Read/ICD-10) were indexed (Dec-2009 to Nov-2017) on a moderate-to-severe pain event (which included TJR) occurring within an episode of chronic pain. 5-year TJR rates from indexing were assessed via Kaplan-Meier estimates. All-cause healthcare resource utilisation and direct medical costs were evaluated in the 1–12 and 13–24 months prior to the first TJR experienced after index. Statistical significance was assessed via paired t-tests. The study cohort comprised 5,931 eligible patients (57.9% aged ≥65 years, 59.2% female). 2,176 (36.7%) underwent TJR (knee: 54.4%; hip: 42.8%; other: 2.8%). The 5-year TJR rate was 45.4% (knee: 24.3%; hip: 17.5%; other: 6.8%). Patients experienced more general practitioner consultations in 1–12 months pre-TJR compared with 13–24 months pre-TJR (means: 12.13 vs. 9.61; p<0.0001), more outpatient visits (6.68 vs. 3.77; p<0.0001), more hospitalisations (0.74 vs. 0.62; p=0.0032), and more emergency department visits (0.29 vs. 0.25, p=0.0190). Total time (days) spent as an inpatient was higher in 1–12 months pre-TJR (1.86 vs. 1.07; p<0.0001). Mean total per-patient cost pre-TJR increased from £1,771 (13–24 months) to £2,621 (1–12 months) (p<0.0001). Resource-use and costs incurred were substantially greater in the 12 months immediately prior to TJR, compared with 13–24 months prior. Reasons for increased healthcare and economic burden in the pre-TJR period deserve further exploration as potential targets for efforts to improve patient experience and efficiency of care

Introduction. The development of an algorithm that provides accurate individualised estimates of revision risk could help patients make informed surgical treatment choices. This requires building a survival model based on fixed and modifiable risk factors that predict outcome at the individual level. Here we compare different survival models for predicting prosthesis survivorship after hip replacement for osteoarthritis using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR). Methods. In this comparative study we implemented parametric and flexible parametric (FP) methods and random survival forests (RSF). The overall performance of the parametric models was compared using Akaike information criterion (AIC). The preferred parametric model and the RSF algorithm were further compared in terms of the Brier score, concordance index and calibration via repeated five-fold cross-validation. Results. The dataset contains 327 238 hip replacements for osteoarthritis carried out in England and Wales between 2003 and 2015. The AIC value for the FP model was the lowest. The averages of survival probability estimates are shown in Figure 1. The integrated Brier score of the FP model and the RSF approach over 10 years were similar: 0.011 (95% confidence interval: 0.011–0.011). The concordance index of the FP model at 10 years was 59.4% (95% confidence interval: 59.4%–59.4%). The concordance index was 56.2% (56.1%–56.3%) for the RSF method. Calibration plots for the FP model and the RSF algorithm are presented in Figure 2. Conclusion. The flexible parametric model outperformed other commonly used survival models across chosen validation criteria. However, it does not provide high discriminatory power at the individual level. This might be due to variable outcomes generated by different fixation or bearing types that cannot be captured using a single model. More complex multi-state models may provide better discrimination. For any figures and tables, please contact the authors directly

Aims. The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE. Patients and Methods. We performed a retrospective analysis involving 46 hips in 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips were available for clinical and radiological examination. Mean preoperative age was 13 years, and 14 hips (30%) presented with unstable slips. Mean preoperative slip angle was 64°. Kaplan–Meier survivorship was calculated. Results. At the latest follow-up, the mean Merle d’Aubigné and Postel score was 17 points (14 to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean Hip Disability and Osteoarthritis Outcome Score was 91 points (67 to 100). Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression of osteoarthritis (OA). Two hips (5%) developed AVN of the femoral head and required further surgery. Three other hips (7%) underwent implant revision due to screw breakage or change of wires. Cumulative survivorship was 86% at ten-year follow-up. Conclusion. The modified Dunn procedure for severe SCFE resulted in a low rate of AVN, low risk of progression to OA, and high functional scores at long-term follow-up. The slip deformities were mainly corrected but secondary impingement deformities can develop in some hips and may require further surgical treatment. Cite this article: Bone Joint J 2019;101-B:403–414