In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the ‘package’ of procedures that are available and to justify their practice beyond traditional clinical preference. . In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community. Cite this article: Bone Joint J 2013;95-B:874–6

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The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death.

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This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.

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The aim of this study is to evaluate the clinical results of operative intervention for femoral metastases which were selected based on expected survival and to discuss appropriate surgical strategies.

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO. The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome. Cite this article: Bone Joint J 2013;95-B:95–100

Dual mobility cups have two points of articulation, one between the shell and the polyethylene (external bearing) and one between the polyethylene and the femoral head (internal bearing). Movement occurs at the inner bearing; the outer bearing only moves at extremes of movement. Dislocation after total hip arthroplasty (THA) is a cause of much morbidity and its treatment has significant cost implications. Dual mobility cups provide an increased range of movement and a may reduce the risk of dislocation. . This paper reviews the use of these cups in THA, particularly where stability is an issue. Dual mobility cups may be of benefit in primary THA in patients at a high risk of dislocation, such as those who are older with increased comorbidities and a higher American Association of Anesthesiology grade and those with a neuromuscular disease. They may be used at revision surgery where the risk of dislocation is high, such as in patients with many prior dislocations, or those with abductor deficiency. They may also be used in THA for displaced fractures of the femoral neck, which has a notoriously high rate of dislocation. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):60–3

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We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques. Cite this article: Bone Joint J 2014;96-B:5–18

Aim. Until now, there has been no consensus as to whether stemmed acetabular components are appropriate for use in patients undergoing revision total hip arthroplasty (THA) who have major acetabular defects or pelvic discontinuity. We wished to address this deficiency in the literature. Patients and Methods. We carried out a retrospective study of 35 patients (six men and 29 women) with a mean age of 68 years (37 to 87), with major acetabular defects who underwent revision THA between 2000 and 2012. Results. At a mean follow-up of 63 months (24 to 141), a total of 15 patients (43%) had required at least one further operation. Six implants (17%) loosened aseptically, four (11%) were further revised for infection and two (6%) for technical failure. By taking revision for any reason as the endpoint, the rate of survival of the implant was 61% after five years; by taking revision for aseptic loosening as the end point, it was 78%. The cumulative five-year survival for aseptic loosening was 94% in patients without pelvic discontinuity, and 56% in those with pelvic discontinuity. Conclusion. These results indicate a significantly worse survival in patients with pelvic discontinuity (p = 0.020) and we advise caution in the use of the pedestal component in patients with major acetabular defects and pelvic discontinuity who require revision THA. As a result of these findings we have stopped using this implant and prefer to use particulate bone grafts protected with an anti-protrusion cage and posterior column plate fixation, if necessary. Take home message: Based on these poor results, we advise caution if using the pedestal component in patients with major acetabular defects with the presence of a pelvic discontinuity. . Cite this article: Bone Joint J 2016;98-B:772–9

Symptomatic hip osteonecrosis is a disabling condition with a poorly understood aetiology and pathogenesis. Numerous treatment options for hip osteonecrosis are described, which include non-operative management and joint preserving procedures, as well as total hip replacement (THR). Non-operative or joint preserving treatment may improve outcomes when an early diagnosis is made before the lesion has become too large or there is radiographic evidence of femoral head collapse. The presence of a crescent sign, femoral head flattening, and acetabular involvement indicate a more advanced-stage disease in which joint preserving options are less effective than THR. Since many patients present after disease progression, primary THR is often the only reliable treatment option available. Prior to the 1990s, outcomes of THR for osteonecrosis were poor. However, according to recent reports and systemic reviews, it is encouraging that with the introduction of newer ceramic and/or highly cross-linked polyethylene bearings as well as highly-porous fixation interfaces, THR appears to be a reliable option in the management of end-stage arthritis following hip osteonecrosis in this historically difficult to treat patient population. Cite this article: Bone Joint J 2013;95-B, Supple A:46–50

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

This preliminary study evaluates a combination of bone morphogenetic protein (BMP)-7 and non-vascularised autologous fibular grafting (AFG) for the treatment of osteonecrosis of the femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral heads (five Steinberg stage II, two stage III) in six patients. Pre- and post-operative evaluation included clinical (Harris hip score (HHS), visual analogue scale (VAS) for pain) and radiological assessment (radiographs, quantitative CT) at a mean follow-up of 4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2) and decrease of pain level (mean VAS decrease of 5) as well as retention of the sphericity of the femoral head was noted in five hips at the latest follow-up, while signs of consolidation were apparent from the third post-operative month. One patient (two hips) required bilateral total hip replacement at one year post-operatively. In the series as a whole, quantitative-CT evaluation revealed similar densities between affected and normal bone. Heterotopic ossification was observed in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and effective method for the treatment of femoral head osteonecrosis, leading to early consolidation of the AFG and preventing collapse in five of seven hips, while the operative time and post-operative rehabilitation period were much shorter compared with free vascularised fibular grafts. Cite this article: Bone Joint J 2014;96-B:31–5

The use of bisphosphonates in the treatment of avascular necrosis of the femoral head is an encouraging but relatively new option with most published data being derived from small trials with limited follow-up. We present a clinicoradiological analysis of 395 hips with avascular necrosis which were treated with oral alendronate for three years with a mean follow-up of four years (1 to 8). Our results show an improvement in the clinical function, a reduction in the rate of collapse and a decrease in the requirement for total hip replacement, compared with the findings of other studies in which no treatment was given. This improvement is particularly marked if the treatment is begun in the pre-collapse stages of the disease. Even in Ficat stage-III hips some benefit was obtained from treatment with alendronate by at least a delay in the need for total hip replacement

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR

Hip resurfacing has been proposed as an alternative to traditional total hip arthroplasty in young, active patients. Much has been learned following the introduction of metal-on-metal resurfacing devices in the 1990s. The triad of a well-designed device, implanted accurately, in the correct patient has never been more critical than with these implants. . Following Food and Drug Administration approval in 2006, we studied the safety and effectiveness of one hip resurfacing device (Birmingham Hip Resurfacing) at our hospital in a large, single-surgeon series. We report our early to mid–term results in 1333 cases followed for a mean of 4.3 years (2 to 5.7) using a prospective, observational registry. The mean patient age was 53.1 years (12 to 84); 70% were male and 91% had osteoarthritis. Complications were few, including no dislocations, no femoral component loosening, two femoral neck fractures (0.15%), one socket loosening (0.08%), three deep infections (0.23%), and three cases of metallosis (0.23%). There were no destructive pseudotumours. Overall survivorship at up to 5.7 years was 99.2%. Aseptic survivorship in males under the age of 50 was 100%. We believe this is the largest United States series of a single surgeon using a single resurfacing system. Cite this article: Bone Joint J 2016;98-B (1 Suppl A):10–13

Post-operative complications after total hip or knee replacement can delay recovery, prolong hospitalisation, increase rates of re-admission and, in the most severe cases, lead to long-term disability or even death. In this analysis of pooled data from four large, randomised, phase III clinical trials that compared the oral, direct Factor Xa inhibitor rivaroxaban with subcutaneous enoxaparin for the prevention of venous thromboembolism after total hip or knee replacement (n = 12 729), the incidence of complications, including bleeding and adverse events related to surgery (such as wound infection, wound dehiscence and haemarthrosis) are reported. Interventions and procedures relating to surgery are also compared between the groups. Bleeding events, including excessive wound haematoma and surgical-site bleeding, occurred at similar rates in the rivaroxaban and enoxaparin groups. Over the total study duration, adverse surgical events occurred at a similar rate in the rivaroxaban group compared with the enoxaparin group after total knee replacement (2.26% vs 2.69%, respectively) and total hip replacement (1.48% vs 1.65%, respectively). Blood loss, wound drainage and transfusion requirements were also similar between the two groups. This analysis shows that the incidence of adverse surgical events with rivaroxaban was similar to enoxaparin