Aims. This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice. Methods. National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man were received for 84,816 RHAs and 818,979 PHAs recorded between April 2011 and December 2019. RHA data comprised all revision procedures, including first-time revisions of PHA and any subsequent re-revisions recorded in public and private healthcare organizations. Annual procedure volumes undertaken by the responsible consultant surgeon in the 12 months prior to every index procedure were determined. We identified a cohort of ‘new’ HA consultants who commenced practice from 2012 and describe their rate of accrual of PHA and RHA experience. Results. The median annual consultant RHA volume, averaged across all cases, was 21 (interquartile range (IQR) 11 to 34; range 0 to 181). Of 1,695 consultants submitting RHA cases within the study period, the top 20% of surgeons by annual volume performed 74.2% of total RHA case volume. More than half of all consultants who had ever undertaken a RHA maintained an annual volume of just one or fewer RHA, however, collectively contributed less than 3% of the total RHA case volume. Consultant PHA and RHA volumes were positively correlated. Lower-volume surgeons were more likely to undertake RHA for urgent indications (such as infection) as a proportion of their practice, and to do so on weekends and public holidays. Conclusion. The majority of RHAs were undertaken by higher-volume surgeons. There was considerable variation in RHA volumes by indication, day of the week, and between consultants nationally. The rate of accrual of RHA experience by new consultants is low, and has important implications for establishing an experienced RHA consultant workforce. Cite this article: Bone Joint J 2023;105-B(10):1060–1069

Aims. The aim of this study was to determine satisfaction rates after hip and knee arthroplasty in patients who did not respond to postoperative patient-reported outcome measures (PROMs), characteristics of non-responders, and contact preferences to maximize response rates. Methods. A prospective cohort study of patients planned to undergo hip arthroplasty (n = 713) and knee arthroplasty (n = 737) at a UK university teaching hospital who had completed preoperative PROMs questionnaires, including the EuroQol five-dimension health-related quality of life score, and Oxford Hip Score (OHS) and Oxford Knee Score (OKS). Follow-up questionnaires were sent by post at one year, including satisfaction scoring. Attempts were made to contact patients who did not initially respond. Univariate, logistic regression, and receiver operator curve analysis was performed. Results. At one year, 667 hip patients (93.5%) and 685 knee patients (92.9%) had undergone surgery and were alive. No response was received from 151/667 hip patients (22.6%), 83 (55.0%) of whom were ultimately contacted); or from 108/685 knee patients (15.8%), 91 (84.3%) of whom were ultimately contacted. There was no difference in satisfaction after arthroplasty between initial non-responders and responders for hips (74/81 satisfied vs 476/516 satisfied; p = 0.847) or knees (81/93 satisfied vs 470/561 satisfied; p = 0.480). Initial non-response and persistent non-response was associated with younger age, higher BMIs, and worse preoperative PROMs for both hip and knee patients (p < 0.050). Being in employment was associated with persistent non-response for hip patients (p = 0.047). Multivariate analysis demonstrated that younger age (p < 0.038), higher BMI (p = 0.018), and poorer preoperative OHS (p = 0.031) were independently associated with persistent non-response to hip PROMs. No independent associations were identified for knees. Using a threshold of > 66.4 years predicted a preference for contact by post (area under the curve 0.723 (95% confidence interval (CI) 0.647 to 0.799; p < 0.001, though this CI crosses the 0.7 limit considered reliable). Conclusion. The majority of initial non-responders were ultimately contactable with effort. Satisfaction rates were not inferior in patients who did not initially respond to PROMs. Cite this article: Bone Jt Open 2022;3(4):275–283

Objectives. T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty. Methods. In this prospective case-control study, PB and SF were obtained from 22 patients (23 hips) undergoing revision of MoM (n = 14) and MoP (n = 9) hip arthroplasties, with eight controls provided from primary hip osteoarthritis cases awaiting arthroplasty. Lymphocyte subtypes in samples were analysed using flow cytometry. Results. The percentages of CD4+ T-cell subtypes in PB were not different between groups. The CD4+ T-cells in the SF of MoM hips showed a completely different distribution of phenotypes compared with that found in the PB in the same patients, including significantly decreased CD4+ T-central memory cells (p < 0.05) and increased T-effector memory cells (p < 0.0001) in the SF. Inducible co-stimulator (ICOS) was the only co-stimulatory molecule with different expression on CD4+ CD28+ cells between groups. In PB, ICOS expression was increased in MoM (p < 0.001) and MoP (p < 0.05) cases compared with the controls. In SF, ICOS expression was increased in MoM hips compared with MoP hips (p < 0.05). Conclusions. Increased expression of ICOS on CD4+ T-cells in PB and SF of patients with failed arthroplasties suggests that these cells are activated and involved in generating immune responses. Variations in ICOS expression between MoM and MoP hips may indicate different modes of arthroplasty failure. Cite this article: Professor P. A. Revell. Increased expression of inducible co-stimulator on CD4+ T-cells in the peripheral blood and synovial fluid of patients with failed hip arthroplasties. Bone Joint Res 2016;5:52–60. doi: 10.1302/2046-3758.52.2000574

Aims

This study aims to evaluate the impact of metabolic syndrome in the setting of obesity on in-hospital outcomes and resource use after total joint replacement (TJR).

Introduction: Despite significant progress at the molecular level the etiology of aseptic loosening is still unclear. Fibrosis of the new capsule is an invariable finding at revision hip arthroplasty. Tissue fibrosis has been demonstrated in varies pathologic conditions due to elevated oxidative stress. The present retrospective study was designed to proof the hypothesis that peri-prosthetic fibrosis in aseptic loosening may be caused by elevated oxidative stress and represent an initial step in the pathomechanism of aseptic loosening. Material and methods: Levels of malondialdehyde (MDA), oxidized (GSSG) and reduced (GSH) gluthatione were assayed as markers of oxidative stress in retrieved capsules of 28 loose hips (Group I) and 12 hips revised for high rate of wear (Group II). Collagen in the periprosthetic tissues was measured as hydroxiproline content and semiquantitatively by electrophoresis. In four representative cases electron microscopy was performed. Results: MDA level as well as GSH/GSSG and GSH/ GSSG² ratios showed elevated oxidative stress in group I compared to group II and controls. SDS-PAGE electrophoresis showed higher molecular bands in 20 patients compared to controls. Hydroxiproline level in group II is significantly higher than in group I (p< 0.05). MDA, GSH and GSSG correlate significantly with hydroxiproline. A negative correlation between collagen content and osteolysis was established. Discussion and conclusion: Higher oxidative stress plays role in aseptic loosening of hip arthroplasty. The present data support the hypothesis that the process is initiated by excessive fibrosis which consequently might lead to increase of intraarticular pressure and to extension of the joint space

In recent years, there has been increasing interest in the use of simultaneous hip arthroplasty compared to staged procedures in patients with bilateral pathology. The aim of this study was to compare simultaneous and staged hip arthroplasty in patients with bilateral pathology by assessing the transfusion rate, postoperative hemoglobin drop, length of stay (LOS), in-hospital complications, 30-days readmissions, leg length difference and early functional outcome. We conducted a retrospective cohort study that included all patients who were undergoing primary total hip arthroplasty (THA) by a single surgeon in a high-volume arthroplasty center between 2015 and 2020 as simultaneous or staged procedures. Staged bilateral arthroplasties were performed within 12 months and were stratified by the time between procedures. Data was acquired through the electronic files at the Orthopädische Chirurgie München (OCM). For functional outcome we compared the ability of the patients to walk independently on the ward and the ability to walk a set of stairs alone which was recorded daily by the attending physiotherapist. In total n=290 patients were assessed for eligibility and included in this study. One hundred and thirty eight patients were allocated to the staged arthroplasty group. The second staged procedure was performed within 12 months of the first procedure. One hundred and fifty two patients were allocated to the simultaneous arthroplasty group. No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: There was no significant difference in transfusion rate or complication rate (p=0.1147). In both groups the transfusion rate was actually 0%. Secondarily, no statistically significant difference was found between the postoperative hemoglobin drop (p=0.1147) and the functional outcome (p=0.7249), nor the length of stay (LOS) (p=: 0.6415), as well as the 30 days readmission rate between both groups. No difference was found in leg length in the simultaneous group. The OR time in the simultaneous group ranged from 62min to 111min with an average of 77min. No surgery exceeded a 120min window. We observed no significant differences in transfusion rate, in hospital complications, as well as readmission rate between both groups. The early functional outcome showed no significant difference in mobility. Simultaneous hip arthroplasty is as safe as a staged procedure, with no higher risk for the patient, in a specialized high volume center with a specialized surgeon and an adequate team. Level of evidence: Level IV

Aims. Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA). Methods. Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications. Results. A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334). Conclusion. Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients. Cite this article: Bone Joint J 2024;106-B(3 Supple A):17–23

Aims. The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods. An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results. Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion. We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity. Cite this article: Bone Joint J 2023;105-B(10):1038–1044

Aims. Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery. Methods. A systematic literature search was performed of MEDLINE, Embase, and grey literature databases to include all studies which compare day-case with inpatient knee and hip replacement. Meta-analyses were performed where appropriate using a random effects model. The protocol was registered prospectively (PROSPERO CRD42023392811). Results. A total of 38 studies were included, with a total of 83,888 day-case procedures. The studies were predominantly from the USA and Canada, observational, and with a high risk of bias. Day-case patients were a mean of 2.08 years younger (95% CI 1.05 to 3.12), were more likely to be male (odds ratio (OR) 1.3 (95% CI 1.19 to 1.41)), and had a lower mean BMI and American Society of Anesthesiologists grades compared with inpatients. Overall, day-case surgery was associated with significantly lower odds of readmission (OR 0.83 (95% CI 0.73 to 0.96); p = 0.009), subsequent emergency department attendance (OR 0.62 (95% CI 0.48 to 0.79); p < 0.001), and complications (OR 0.7 (95% CI 0.55 to 0.89) p = 0.004), than inpatient surgery. There were no significant differences in the rates of reoperation or mortality. The overall rate of successful same-day discharge for day-case surgery was 85% (95% CI 81 to 88). Patient-reported outcome measures and cost-effectiveness were either equal or favoured day-case. Conclusion. Within the limitations of the literature, in particular the substantial risk of selection bias, the outcomes following day-case knee and hip replacement appear not to be inferior to those following an inpatient stay. The evidence is more robust for unicompartmental knee replacement (UKR) than for total knee replacement (TKR) or total hip replacement (THR). The rate of successful same-day discharge is highest in UKR, followed by TKR and comparatively lower in THR. Cite this article: Bone Joint J 2024;106-B(12):1385–1392

Aims. To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results. Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion. This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. Cite this article: Bone Joint J 2024;106-B(4):401–411

Aims. Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design. Methods. Patients with end-stage osteoarthritis were enrolled in a prospective cohort at a single centre. The cohort consisted of 11 females and 11 males with mean age of 70.6 years (SD 3.5) and BMI of 31.0 kg/m. 2. (SD 5.7). Implant fixation was evaluated using RSA as well as Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score, Oxford Hip Score, Hip disability and Osteoarthritis Outcome Score, 38-item Short Form survey, and EuroQol five-dimension health questionnaire scores at two-year follow-up. At least one acetabular screw was used in all cases. RSA markers were inserted into the innominate bone and proximal femur with imaging at six weeks (baseline) and six, 12, and 24 months. Independent-samples t-tests were used to compare to published thresholds. Results. Mean acetabular subsidence from baseline to 24 months was 0.087 mm (SD 0.152), below the critical threshold of 0.2 mm (p = 0.005). Mean femoral subsidence from baseline to 24 months was -0.002 mm (SD 0.194), below the published reference of 0.5 mm (p < 0.001). There was significant improvement in patient-reported outcome measures at 24 months with good to excellent results. Conclusion. RSA analysis demonstrates excellent fixation with a predicted low risk of revision at ten years of this novel reverse total hip system. Clinical outcomes were consistent with safe and effective hip replacement prostheses. Cite this article: Bone Jt Open 2023;4(5):385–392

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery. We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip. Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially. The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller. By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm)

Climbers and mountaineers will present to arthroplasty surgeons in need of hip replacement surgeries. There is a lack of guidance for both parties with a paucity in the literature. Climbing is often considered a high-risk activity to perform with a total hip replacement, due to the positions the hip is weighted in, and the potential austere environment in which an injury may occur. The aim was to assess levels of climbing and mountaineering possible following hip arthroplasty, and any factors affecting these levels. Ethical approval was obtained from the University of Central Lancashire. An anonymous online questionnaire was disseminated via email, social media and word-of-mouth to include all climbers, hill-walkers or mountaineers across the UK. This was used to collect climbing and mountaineering ability at various timepoints, along with scores such as the Oxford Hip Score and UCLA Score. The Kappa statistic was used to assess for correlations. Of the responders, 28 had undergone right hip arthroplasty surgery, with 11 having left hips and 22 receiving bilateral hips. A total of 67 of the replaced hips were total hip replacements, with 16 having undergone hip resurfacing. There is a fair agreement in level of climbing ability 3 months pre- and 3 months post-operatively (kappa=0.287, p<0.001), and a substantial agreement between 1 year post-operatively and currently for both climbing (kappa=0.730, p<0.001) and mountaineering (kappa=0.684, p<0.001). Impressively, 17 participants are climbing at more than E1 trad or 6c sport at one or more time points post operatively, which is regarded as an advanced level within the climbing community. Out of those 17 participants, 8 were climbing at this level within 3 months post-operatively. The level of climbing possible following hip arthroplasty surgery is above what is expected and perhaps desired by the operating surgeon. It is essential to take the individual patient into account when planning an operative intervention such as arthroplasty. The one year post-operative time point is highly predictive of longer term outcomes for both climbing and mountaineering

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Aims. The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells. Methods. HIPGEN is a multicentre, multinational, randomized, double-blind, placebo-controlled trial. A total of 240 patients aged 60 to 90 years with low-energy femoral neck fractures (FNF) will be allocated to two arms and receive an intramuscular injection of either 150 × 10. 6. PLX-PAD cells or placebo into the medial gluteal muscle after direct lateral implantation of total or hemi hip arthroplasty. Patients will be followed for two years. The primary endpoint is the Short Physical Performance Battery (SPPB) at week 26. Secondary and exploratory endpoints include morphological parameters (lean body mass), functional parameters (abduction and handgrip strength, symmetry in gait, weightbearing), all-cause mortality rate and patient-reported outcome measures (Lower Limb Measure, EuroQol five-dimension questionnaire). Immunological biomarker and in vitro studies will be performed to analyze the PLX-PAD mechanism of action. A sample size of 240 subjects was calculated providing 88% power for the detection of a 1 SPPB point treatment effect for a two-sided test with an α level of 5%. Conclusion. The HIPGEN study assesses the efficacy, safety, and tolerability of intramuscular PLX-PAD administration for the treatment of muscle injury following arthroplasty for hip fracture. It is the first phase III study to investigate the effect of an allogeneic cell therapy on improved mobilization after hip fracture, an aspect which is in sore need of addressing for the improvement in standard of care treatment for patients with FNF. Cite this article: Bone Jt Open 2022;3(4):340–347

Aims. With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases. Methods. A retrospective review of 25 patients who underwent PFA for non-neoplastic indications between January 2009 and December 2015 was undertaken. Their clinical and radiological outcome, complication rates, and survival were recorded. All patients had the Stanmore Implant – Modular Endo-prosthetic Tumour System (METS). Results. At mean follow-up of 5.9 years, there were no periprosthetic fractures. Clearance of infection was achieved in 63.6% of cases. One hip was re-revised to pseudo arthroplasty for deep infection. Instability was noted in eight of the hips (32%), of which seven needed further surgery. Out of these eight hips with instability, five had preoperative infection. Deep infection was noted in five of the hips (20%), of which four were primarily revised for infection. One patient had aseptic loosening of the femoral component and awaits revision surgery. The Kaplan-Meier survivorship free of revision of any component for any reason was 72% (95% confidence interval (CI) 51.3% to 92.7%), and for revisions of only femoral component for any reason was 96% (95% CI 86.3% to 105.7%) at five years. Conclusion. Dislocation and infection remain the major cause for failure, particularly in patients with pre-existing infection. The use of dual mobility cups, silver-coated implants, and less aggressive postoperative rehabilitation regimens would possibly aid in the reduction of complications. PFA performed in patients with periprosthetic fracture seem to fair better. This study supports the judicious use of PFA in non-oncological revision hip arthroplasties, and that they be performed by experienced revision arthroplasty surgeons. Cite this article: Bone Jt Open 2022;3(3):229–235

Aims. Although the short stem concept in hip arthroplasty procedure shows acceptable clinical performance, we sometimes get unexplainable radiological findings. The aim of this retrospective study was to evaluate changes of radiological findings up to three years postoperatively, and to assess any potential contributing factors on such radiological change in a Japanese population. Methods. This is a retrospective radiological study conducted in Japan. Radiological assessment was done in accordance with predetermined radiological review protocol. A total of 241 hips were included in the study and 118 hips (49.0%) revealed radiological change from immediately after surgery to one year postoperatively; these 118 hips were eligible for further analyses. Each investigator screened whether either radiolucent lines (RLLs), cortical hypertrophy (CH), or atrophy (AT) appeared or not on the one-year radiograph. Further, three-year radiographs of eligible cases were reviewed to determine changes such as, disappeared (D), improved (I), stable (S), and progression (P). Additionally, bone condensation (BC) was assessed on the three-year radiograph. Results. CH was observed in 49 hips (21.1%), AT was observed in 63 hips (27.2%), and RLLs were observed in 34 hips (14.7%) at one year postoperatively. Among 34 hips with RLLs, 70.6% showed change of either D or I on the three-year radiograph. BC was observed in younger patients more frequently. Conclusion. The Fitmore stem works well in a Japanese population with favourable radiological change on hips with RLLs. Longer-term follow-up is required to determine clinical relevance. Cite this article: Bone Jt Open 2022;3(1):20–28

The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9. th. February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of bias only. For revision hip arthroplasty patients receiving ICS, 37.07% required ABT with a mean transfusion of 1.92 units or 385ml per patient. For patients treated without ICS, 64.58% required ABT with a mean transfusion of 4.02 units or 803ml per patient. This difference achieved statistical significance (p < 0.05). This study has demonstrated a significant reduction in the need for allogenic blood transfusion associated with intra-operative cell salvage use among patients undergoing revision hip arthroplasty. This study therefore supports the routine use of ICS in this patient group. However, a major limitation is the lack of clinical outcomes reported by the available studies. Further research is required to determine whether this effect is associated with sub-groups of revision arthroplasty procedure, and whether ICS impacts clinical outcomes such as length of stay, rehabilitation progress and mortality

Total hip arthroplasty (THA) has proved to be an effective treatment modality for sickle-cell hip arthropathy (mosaic-like dense bone due to infarcts). However, mode of failure, survival rates and challenges associated with revision hip arthroplasty in sickle-cell disease patients are mostly unknown. We retrospectively evaluated prospectively collected data from all patients with sickle-cell disease who underwent revision hip arthroplasty from 2016. Patient, surgery, medical and surgical complications related data were collected. The pinnacle and reclaim revision system with gription augments (JJ) was used in all patients. Pre-op and post-op clinical outcome data (both objective and subjective, HOOS Jr and OHS) were recorded. Cumulative success rates were recorded with re-revision surgery as an end point. We performed fifteen revision THAs on 13 patients (mean follow up of 6.6 years). The mean age of the patients was 48 years (range, 30–59). At final follow-up, a statistically significant improvement of mean OHS and HOOS JR scores eas found in all patients. reported (OHS: 34.0 and HOOS JR: 77.7). Cumulative success rate was 100% for re-revision for all reasons at 6 years. Five intensive care unit (ITU) admissions, two vaso-occlusive sickle cell crises, one transfusion-related complication and one acute chest syndrome (ACS) were recorded. On admission, the mean percentage of HbS was 75.25% (64.6–86.4%). Revision arthroplasty in sickle-cell disease patients poses increased risks, with medical and surgical challenges. However, with careful preparation, planning and a multi-disciplinary team approach, revision arthroplasty can result in excellent clinical outcomes and excellent functional scores in the majority of patients in the short and mid-term

Aims. There is an increasing demand for hip arthroplasty in China. We aimed to describe trends in in-hospital mortality after this procedure in China and to examine the potential risk factors. Patients and Methods. We included 210 450 patients undergoing primary hip arthroplasty registered in the Hospital Quality Monitoring System in China between 2013 and 2016. In-hospital mortality after hip arthroplasty and its relation to potential risk factors were assessed using multivariable Poisson regression. Results. During the study period, 626 inpatient deaths occurred within 30 days after hip arthroplasty. Mortality decreased from 2.9% in 2013 to 2.6% in 2016 (p for trend = 0.02). Compared with their counterparts, old age, male sex, and divorced or widowed patients had a higher rate of mortality (all p < 0.05). Risk ratio (RR) for mortality after arthroplasty for fracture was two-fold higher (RR 2.0, 95% confidence interval (CI) 1.5 to 2.6) than that for chronic disease. RRs for mortality were 3.3 (95% CI 2.7 to 3.9) and 8.2 (95% CI 6.5 to 10.4) for patients with Charlson Comorbidity Index (CCI) of 1 to 2 and CCI ≥ 3, respectively, compared with patients with CCI of 0. The rate of mortality varied according to geographical region, the lowest being in the East region (1.8%), followed by Beijing (2.1%), the North (2.9%), South-West (3.6%), South-Central (3.8%), North-East (4.1%), and North-West (5.2%) regions. Conclusion. While in-hospital mortality after hip arthroplasty in China appears low and declined during the study period, discrepancies in mortality after this procedure exist according to sociodemographic factors. Healthcare resources should be allocated more to underdeveloped regions to further reduce mortality. Cite this article: Bone Joint J 2019;101-B:1209–1217