Aims. Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. Methods. Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. Results. TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. Conclusion. Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements. Cite this article: Bone Joint Open 2020;1-7:398–404

Aims. The aim of this study was to evaluate the diagnostic accuracy of the synovial alpha-defensin enzyme-linked immunosorbent assay (ELISA) for the diagnosis of prosthetic joint infection (PJI) in the work-up prior to revision of total hip (THA) and knee arthroplasty (TKA). Patients and Methods. Inclusion criteria for this prospective cohort study were acute or chronic symptoms of the index joint without specific exclusion criteria. Synovial fluid aspirates of 202 patients were analyzed and semiquantitative laboratory alpha-defensin ELISA was performed. Final diagnosis of PJI was established by examination of samples obtained during revision surgery. Results. Sensitivity and specificity of the alpha-defensin ELISA for PJI were 78.2% (95% confidence interval (CI) 66.7 to 88.5) and 96.6% (95% CI 93.0 to 99.3). Positive and negative predictive values were 89.6% (95% CI 80.6 to 97.8) and 92.2% (95% CI 87.5 to 96.1). The test remained false-negative in 22% of septic revisions, most of which were due to coagulase-negative staphylococci all occurring in either late-chronic or early-postoperative PJI. Conclusion. The routine use of synovial fluid alpha-defensin laboratory ELISA in the preoperative evaluation of symptomatic THAs and TKAs is insufficient to accurately diagnose PJI. Particularly in cases involving low-virulence organisms, such as coagulase-negative staphylococci, there remains a need for tests with a higher sensitivity. Cite this article: Bone Joint J 2019;101-B:970–977

Aims. Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants. Methods. All hip fracture patients aged 18 to 60 years admitted to a single centre over a 15-year period were used to identify the study group. Fracture pattern (undisplaced intracapsular, displaced intracapsular, and extracapsular) and type of operation (multiple cannulated hip screws, angular stable fixation, hemiarthroplasty, and total hip replacement) were recorded. The primary outcome measures were the Oxford Hip Score (OHS), the EuroQol five-dimension questionnaire (EQ-5D-3L), and EQ-visual analogue scale (VAS) scores. Preinjury scores were recorded by patient recall and postinjury scores were collected at a mean of 57 months (9 to 118) postinjury. Ethics approval was obtained prior to study commencement. Results. A total of 72 patients were included. There was a significant difference in pre- and post-injury OHS (mean 9.8 point reduction (38 to -20; p < 0.001)), EQ-5D (mean 0.208 reduction in index (0.897 to -0.630; p < 0.001)), and VAS , and VAS (mean 11.6 point reduction (70 to -55; p < 0.001)) Fracture pattern had a significant influence on OHS (p < 0.001) with extracapsular fractures showing the least favourable long-term outcome. Fixation type also impacted significantly on OHS (p = 0.011) with the worst outcomes in patients treated by hemiarthroplasty or angular stable fixation. Conclusion. There is a significant reduction in function and quality of life following injury, with all three patient-reported outcome measures used, indicating that this is a substantial injury in younger patients. Treatment with hemiarthroplasty or angular stable devices in this cohort were associated with a less favourable hip score outcome. Cite this article: Bone Joint J 2020;102-B(6):766–771

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Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England.

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The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

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Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs.

Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. Patients and Methods. Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. Results. A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). Conclusion. Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use. Cite this article: Bone Joint J 2019;101-B:1570–1577

Objectives. Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties. Methods. A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group. Results. An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06). Conclusions. Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications. Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

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Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors.

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Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more meaningful estimate of risk projection over a patient’s remaining lifetime, and to compare this to TKA.

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BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems.

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The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA.

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Navigation devices are designed to improve a surgeon’s accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error.

Aims. Femoral impaction bone grafting was first developed in 1987 using morselised cancellous bone graft impacted into the femoral canal in combination with a cemented, tapered, polished stem. We describe the evolution of this technique and instrumentation since that time. . Patients and Methods. Between 1987 and 2005, 705 revision total hip arthroplasties (56 bilateral) were performed with femoral impaction grafting using a cemented femoral stem. All surviving patients were prospectively followed for a mean of 14.7 years (9.8 to 28.3) with no loss to follow-up. By the time of the final review, 404 patients had died. Results. There were 76 further revisions (10.8%) involving the stem; seven for aseptic loosening, 23 for periprosthetic fracture, 24 for infection, one for malposition, one for fracture of the stem and 19 cement-in-cement exchanges of the stem during acetabular revision. The 20-year survival rate for the entire series was 98.8% (95% confidence interval (CI) 97.8 to 99.8) with aseptic loosening as the endpoint, and 87.7% (95% CI 82.8 to 92.6) for revision for any reason. Survival improved with the evolution of the technique, although this was not statistically significant due to the overall low rate of further revision. Conclusion. This is the largest series of revision total hip arthroplasties with femoral impaction grafting, and the results support the continued use of this technique. Cite this article: Bone Joint J 2016;98-B:1611–19

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Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures.

Aims. Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure. Patients and Methods. We retrospectively identified 19 hips (19 patients) that had undergone repeat two-stage revision THA for infection between 2000 to 2013. There were seven female patients (37%) and the mean age was 60 years (30 to 85). Survival free from revision was assessed via Kaplan–Meier analysis. The patients were classified according to the Musculoskeletal Infection Society (MSIS) system, and risk factors for failure were identified. Mean follow-up was four years (2 to 11). Results. Gram-positive bacteria were responsible for 16/17 (94%) of the re-infections where microbes were identified. Following the repeat two-stage exchange arthroplasty, survival free from any revision was 74% (95% confidence interval (CI) 56% to 96%, 14 at risk) at two years and 45% (95% CI 25% to 75%, five at risk) at five years. Failure to control infection resulted in re-operation or revision in 42%A of patients (8/19). Survival free from revision was not dependent on host grade. Conclusion. Re-infection after two-stage exchange hip arthroplasty for PJI presents a challenging scenario. Repeat two-stage exchange arthroplasty has a low survival free from revision at five years (45%) and a high rate of re-infection (42%). Cite this article: Bone Joint J 2018;100-B:1157–61