Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons’ competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.

Cite this article: Bone Joint J 2013;95-B:1445–9.

Aims

The Single Assessment Numerical Evalution (SANE) score is a pragmatic alternative to longer patient-reported outcome measures (PROMs). The purpose of this study was to investigate the concurrent validity of the SANE and hip-specific PROMs in a generalized population of patients with hip pain at a single timepoint upon initial visit with an orthopaedic surgeon who is a hip preservation specialist. We hypothesized that SANE would have a strong correlation with the 12-question International Hip Outcome Tool (iHOT)-12, the Hip Outcome Score (HOS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), providing evidence for concurrent validity of the SANE and hip-specific outcome measures in patients with hip pain.

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

Given the increasing number of total hip arthroplasty procedures being performed annually, it is imperative that orthopaedic surgeons understand factors responsible for instability. In order to treat this potentially complex problem, we recommend correctly classifying the type of instability present based on component position, abductor function, impingement, and polyethylene wear. Correct classification allows the treating surgeon to choose the appropriate revision option that ultimately will allow for the best potential outcome.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):44–9.

Aims

Vitamin E-diffused, highly crosslinked polyethylene (VEPE) and porous titanium-coated (PTC) shells were introduced in total hip arthroplasty (THA) to reduce the risk of aseptic loosening. The purpose of this study was: 1) to compare the wear properties of VEPE to moderately crosslinked polyethylene; 2) to assess the stability of PTC shells; and 3) to report their clinical outcomes at seven years.

Since January 1993 we have carried out MR arthrography on 23 patients with clinical symptoms and signs of abnormality of the acetabular labrum. Most of the patients were young adults. Such symptoms are known precursors of osteoarthritis, and therefore early and accurate evaluation is required.

We assessed the value of MR arthrography of the hip as a minimally-invasive diagnostic technique, in a prospective study and compared the findings with those at subsequent operations. All the patients complained of groin pain; 22 had a positive acetabular impingement test and 15 had radiological evidence of hip dysplasia.

In 21 of the patients, MR arthrography suggested either degeneration or a tear of the labrum or both. These findings were confirmed at operation in 18 patients, but there was no abnormality of the labrum in the other three. In two of the patients, MR arthrography erroneously suggested an intact labrum. Both MR arthrography and intraoperative inspection located lesions of the superior labrum most often, and these appeared slightly larger on arthrography than at operation.

We consider that MR arthrography is a promising diagnostic technique for the evaluation of abnormalities of the acetabular labrum.

The cam-type deformity in femoroacetabular impingement is a 3D deformity. Single measurements using radiographs, CT or MRI may not provide a true estimate of the magnitude of the deformity. We performed an analysis of the size and location of measurements of the alpha angle (α°) using a CT technique which could be applied to the 3D reconstructions of the hip. Analysis was undertaken in 42 patients (57 hips; 24 men and 18 women; mean age 38 years (16 to 58)) who had symptoms of femoroacetabular impingement related to a cam-type abnormality. An α° of > 50° was considered a significant indicator of cam-type impingement. Measurements of the α° were made at different points around the femoral head/neck junction at intervals of 30°: starting at the nine o’clock (posterior), ten, eleven and twelve o’clock (superior), one, two and ending at three o’clock (anterior) position.

The mean maximum increased α° was 64.6° (50.8° to 86°). The two o’clock position was the most common point to find an increased α° (53 hips; 93%), followed by one o’clock (48 hips; 84%). The largest α° for each hip was found most frequently at the two o’clock position (46%), followed by the one o’clock position (39%). Generally, raised α angles extend over three segments of the clock face.

Single measurements of the α°, whether pre- or post-operative, should be viewed with caution as they may not be representative of the true size of the deformity and not define whether adequate correction has been achieved following surgery.

Cite this article: Bone Joint J 2014;96-B:1167–71.

Three radiological methods are commonly used to assess the outcome of total hip replacement (THR). They aim to record the appearance of lucent areas and migration of the prosthesis in a reproducible manner. Two of them were designed to monitor the implant through time and one to grade the quality of cementing. We have measured the level of inter- and intraobserver agreement in all three systems.

We randomised 30 patients to receive either finger packing or retrograde gun cementing during Charnley hip replacements. The postoperative departmental radiographs were evaluated in a blinded study by two orthopaedic trainees, two consultants and two experts in THR. The trainees and consultants repeated the exercise at least two weeks later. We used the unweighted kappa statistic to establish the levels of agreement.

In general, intraobserver agreement was moderate but interobserver agreement was poor, with levels similar to or less than those expected by chance. Our results indicate that such systems cannot provide reliable data from centres in different parts of the world, with various levels of surgeon evaluating radiographs at differing time intervals. We discuss the problem and suggest some methods of improvement.

We have evaluated the results of total hip replacement in patients with congenital hip disease using 46 cemented all-polyethylene Charnley acetabular components implanted with the cotyloplasty technique in 34 patients (group A), and compared them with 47 metal-backed cementless acetabular components implanted without bone grafting in 33 patients (group B). Patients in group A were treated between 1988 and 1993 and those in group B between 1990 and 1995. The mean follow-up for group A was 16.6 years (12 to 18) and the mean follow-up for group B was 13.4 years (10 to 16).

Revision for aseptic loosening was undertaken in 15 hips (32.6%) in group A and in four hips (8.5%) in group B. When liner exchange was included, a total of 13 hips were revised in group B (27.7%). The mean polyethylene wear was 0.11 mm/yr (0.002 to 0.43) and 0.107 mm/yr (0 to 0.62) for groups A and B, respectively. Polyethylene wear in group A was associated with linear osteolysis, and in group B with expansile osteolysis.

In patients with congenital hip disease, when 80% cover of the implant can be obtained, a cementless acetabular component appears to be acceptable and provides durable fixation. However, because of the type of osteolysis arising with these devices, early exchange of a worn liner is recommended before extensive bone loss makes revision surgery more complicated.

Aims. Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods. In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results. The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion. The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches. Cite this article: Bone Joint J 2023;105-B(12):1252–1258

Aims. Cemented hemiarthroplasty is an effective form of treatment for most patients with an intracapsular fracture of the hip. However, it remains unclear whether there are subgroups of patients who may benefit from the alternative operation of a modern uncemented hemiarthroplasty – the aim of this study was to investigate this issue. Knowledge about the heterogeneity of treatment effects is important for surgeons in order to target operations towards specific subgroups who would benefit the most. Methods. We used causal forest analysis to compare subgroup- and individual-level treatment effects between cemented and modern uncemented hemiarthroplasty in patients aged > 60 years with an intracapsular fracture of the hip, using data from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized clinical trial. EuroQol five-dimension index scores were used to measure health-related quality of life at one, four, and 12 months postoperatively. Results. Our analysis revealed a complex landscape of responses to the use of a cemented hemiarthroplasty in the 12 months after surgery. There was heterogeneity of effects with regard to baseline characteristics, including age, pre-injury health status, and lifestyle factors such as alcohol consumption. This heterogeneity was greater at the one-month mark than at subsequent follow-up timepoints, with particular regard to subgroups based on age. However, for all subgroups, the effect estimates for quality of life lay within the confidence intervals derived from the analysis of all patients. Conclusion. The use of a cemented hemiarthroplasty is expected to increase health-related quality of life compared with modern uncemented hemiarthroplasty for all subgroups of patients aged > 60 years with a displaced intracapsular fracture of the hip. Cite this article: Bone Joint J 2024;106-B(7):656–661

Aims. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA). Methods. This study is a secondary analysis of patients aged 50 years or older with a displaced femoral neck fracture who were enrolled in the HEALTH trial and underwent monopolar and bipolar HA. Scores from the Western Ontario and McMaster University Arthritis Index (WOMAC) and 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and (MCS) were compared between the two HA groups using a propensity score-weighted analysis. Results. Of 746 HAs performed in the HEALTH trial, 404 were bipolar prostheses and 342 were unipolar. After propensity score weighting, adequate balance between the bipolar and unipolar groups was obtained as shown by standardized mean differences less than 0.1 for each covariable. A total of 24 months after HA, the total WOMAC score and its subcomponents showed no statistically significant difference between the unipolar and bipolar groups. Similarly, no statistically significant difference was found in the PCS and MCS scores of the SF-12 questionnaire. In participants aged 70 years and younger, no difference was found in any of the functional outcomes. Conclusion. From the results of this study, the use of bipolar HA over unipolar design does not provide superior functional outcomes at 24 months postoperatively. The theoretical advantage of reduced acetabular wear with bipolar designs does not appear to influence functional outcomes in the first two years postoperatively. Cite this article: Bone Jt Open 2023;4(5):370–377

Aims. In 2015, we published the results of our ceramic-on-metal (CoM) total hip arthroplasties (THAs) performed between October 2007 and July 2009 with a mean follow-up of 34 months (23 to 45) and a revision rate of 3.1%. The aim of this paper is to present the longer-term outcomes. Methods. A total of 264 patients were reviewed at a mean of 5.8 years (4.6 to 7.2) and 10.1 years (9.2 to 10.6) to determine revision rate, pain, outcome scores, radiological analysis, and blood ion levels. Those who were unwilling or unable to travel were contacted by telephone. Results. The all-cause revision rate at six years was 3.1% (eight THAs), increasing to 8.8% (18 THAs) at ten years. Of these, there were four and then seven bearing-related revisions at six and ten years, respectively. There was a statistically significant deterioration in the visual analogue scale pain score and Oxford Hip Score (OHS) between six and ten years. There were 18 CoM THAs in 17 patients who had a cobalt or chromium level over 4 ppb and ten CoM THAs in nine patients who had a cobalt or chromium level higher than 7 ppb with a statistically significant increase in chromium levels only between the two timepoints. Overall, 84 stems (39.1%) had significant radiolucent lines at ten years compared to 65 (25.5%) at six years. Conclusion. When compared to the original review, there has been a significant deterioration in pain score, OHS, radiograph appearance, and, most critically, survival has fallen to 91.2%, which does not meet the Orthopaedic Data Evaluation Panel (ODEP) 10 A* 95% threshold. Although this bearing is no longer on the market, 2.5% were bearing-related revisions, which have relevance to the discussion around modular dual-mobility implants that have a similar metal interface

Aims. To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials. Methods. This study included 2,388 patients from the HEALTH and FAITH trials, with 90-day and one-year mortality proportions of 3.0% (71/2,388) and 6.4% (153/2,388), respectively. The mean age was 75.9 years (SD 10.8) and 65.9% of patients (1,574/2,388) were female. The algorithms included patient and injury characteristics. Six algorithms were developed, internally validated and evaluated across discrimination (c-statistic; discriminative ability between those with risk of mortality and those without), calibration (observed outcome compared to the predicted probability), and the Brier score (composite of discrimination and calibration). Results. The developed algorithms distinguished between patients at high and low risk for 90-day and one-year mortality. The penalized logistic regression algorithm had the best performance metrics for both 90-day (c-statistic 0.80, calibration slope 0.95, calibration intercept -0.06, and Brier score 0.039) and one-year (c-statistic 0.76, calibration slope 0.86, calibration intercept -0.20, and Brier score 0.074) mortality prediction in the hold-out set. Conclusion. Using high-quality data, the ML-based prediction models accurately predicted 90-day and one-year mortality in patients aged 50 years or older with a FNF. The final models must be externally validated to assess generalizability to other populations, and prospectively evaluated in the process of shared decision-making. Cite this article: Bone Jt Open 2023;4(3):168–181

Aims. The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults. Methods. A within-trial economic evaluation was conducted based on data collected from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized controlled trial in the UK. Resource use was measured over 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from the NHS and personal social service perspective. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was represented graphically using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that cemented implants were cost-saving (mean cost difference -£961 (95% confidence interval (CI) -£2,292 to £370)) and increased QALYs (mean QALY difference 0.010 (95% CI 0.002 to 0.017)) when compared to uncemented implants. The probability of the cemented implant being cost-effective approximated between 95% and 97% at alternative cost-effectiveness thresholds held by decision-makers, and its net monetary benefit was positive. The findings remained robust against all the pre-planned sensitivity analyses. Conclusion. This study shows that cemented HA is cost-effective compared with hydroxyapatite-coated uncemented HA in older adults with displaced intracapsular hip fractures. Cite this article: Bone Joint J 2022;104-B(8):922–928

Aims. The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population. Methods. We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed. Results. There were 143 patients included in the fittest cohort. Mean age was 66 years (SD 4.5) and 103 were female (72%). No clinically relevant differences were found between the treatment groups in the primary and sensitivity analyses. Conclusion. This analysis found no differences in functional outcomes between HA and THA within two years of displaced low-energy FNF in a subgroup analysis of the fittest HEALTH patients. These findings suggest that very few patients above 50 years of age benefit in a clinically meaningful way from a THA versus a HA early after injury. Cite this article: Bone Jt Open 2022;3(8):611–617

Aims. Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Methods. The study included 42 consecutive hips in 42 patients (three male and 39 female) who underwent PAO from May 2016 to July 2018. We prospectively evaluated the incidence of LFCN injury at ten days, three months, six months, and one year postoperatively. We also evaluated the clinical scores, including the HHS, SF-36, and JHEQ scores, at one year postoperatively. Results. LFCN injury was observed in 31 of 42 (74%) patients at ten days, of which 11 resolved completely by one year. Incidence decreased gradually, to 25 of 42 (60%) patients at three months, 24 of 42 patients (57%) at six months, and 20 of 42 (48%) patients at one year postoperatively. There was no significant difference in the HHS between patients with and without LFCN injury at one year postoperatively. Regarding the SF-36 and JHEQ, a significant difference in the mental score was recognized between patients with and without LFCN injury, but there were no significant differences in the other clinical scores. Conclusion. The incidence of LFCN injury was 74% at ten days after PAO, and subsequently decreased to 48% at one year. LFCN injury did not influence the hip function as assessed by the HHS, but had a negative impact on mental health at one year. Cite this article: Bone Joint J 2021;103-B(4):659–664

Aims. We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH). Methods. This retrospective comparative study included 81 patients with ONFH; 37 patients (40 hips) underwent CVO with BIG (BIG group) and 44 patients (47 hips) underwent CVO alone (CVO group). Patients in the BIG group were followed-up for a mean of 12.2 years (10.0 to 16.5). Patients in the CVO group were followed-up for a mean of 14.5 years (10.0 to 21.0). Assessment parameters included the Harris Hip Score (HHS), Oxford Hip Score (OHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), complication rates, and survival rates, with conversion to total hip arthroplasty (THA) and radiological failure as the endpoints. Results. There were no significant differences in preoperative and postoperative HHS or postoperative OHS and JHEQ between the BIG group and the CVO group. Complication rates were comparable between groups. Ten-year survival rates with conversion to THA and radiological failure as the endpoints were not significantly different between groups. Successful CVO (postoperative coverage ratio of more than one-third) exhibited better ten-year survival rates with radiological failure as the endpoint in the BIG group (91.4%) than in the CVO group (77.7%), but this difference was not significant (p = 0.079). Conclusion. Long-term outcomes of CVO with BIG were favourable when proper patient selection and accurate surgery are performed. However, this study did not show improvements in treatment results with the concomitant use of BIG. Cite this article: Bone Joint J 2021;103-B(4):665–671

Aims. To assess the variation in pre-fracture quality of life (QoL) within the UK hip fracture population, and quantify the nature and strength of associations between QoL and other routinely collected patient characteristics and treatment choices. Methods. The World Hip Trauma Evaluation (WHiTE) study, an observational cohort study of UK hip fracture patients, collects a range of routine data and a health-related QoL score (EuroQol five-dimension questionnaire (EQ-5D)). Pre-fracture QoL data are summarized and statistical models fitted to understand associations between QoL, patient characteristics, fracture types, and operations. Results. Fitting a multiple linear regression model indicated that 36.5% of the variance in pre-fracture EQ-5D scores was explained by routinely collected patient characteristics: sex (0.14%), age (0.17%), American Society of Anesthesiologists (ASA) score (0.73%), Abbreviated Mental Test Score (AMTS; 1.3%), pre-fracture mobility (11.2%), and EQ-5D respondent (participant, relative, or carer; 23.0%). There was considerable variation in pre-fracture EQ-5D scores between operations within fracture types. Participants with trochanteric fractures reported statistically significant but not clinically relevant lower pre-fracture QoL than those with intracapsular fractures. Participants with intracapsular fractures treated with internal fixation or total hip arthroplasty (THA) reported better QoL than those treated with hemiarthroplasty with the overall fittest group receiving THA. Conclusion. Pre-fracture QoL varies considerably between hip fracture patients; it is generally higher in younger than older patients, patients with better mobility, and those patients who live more independently. Pre-fracture QoL is significantly associated with a range of patient characteristics (e.g. age, mobility, residency). These data explain ~35% of the variation in QoL. Cite this article: Bone Joint Res 2020;9(8):468–476

Aim. 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. Methods. A within-trial cost-utility analysis (CUA) will be conducted at four months postinjury from a health system (National Health Service and personal social services) perspective. Resource use pertaining to healthcare utilization (i.e. inpatient care, physiotherapy, social care, and home adaptations), and utility measures (quality-adjusted life years) will be collected at one and four months (primary outcome endpoint) postinjury; only treatment of complications will be captured at 12 months. Sensitivity analysis will be conducted to assess the robustness of the results. Conclusion. The planned analysis strategy described here records our intent to conduct a within-trial CUA alongside the WHiTE5 trial

Aims. This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. Methods. A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. Results. A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. Conclusion. Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate. Cite this article: Bone Joint Res. 2020;9(5):250–257

Aims. The aim of this retrospective audit was to determine the route of referral or presentation of patients requiring revision following primary total hip arthroplasty (THA). Patients and Methods. A total of 4802 patients were implanted with an Orthopaedic Data Evaluation Panel (ODEP) 10A* cementless implant (Corail/Pinnacle) between 2005 and 2015; 80 patients with a mean age of 67.8 years (. sd. 10.8) underwent a subsequent revision. The primary outcome measure was route of referral for revision. Results. Of the 80 revisions, 31 (38.8%) took place within the first year and 69 (86.3%) took place within six years. Only two of the 80 patients were picked up at a routine review clinic, one for infection and the other for liner dissociation. A total of 36 revised patients (45.0%) were reviewed following self-referral. Of the remaining 44 revised patients (55.0%), 15 (18.8%) were General Practitioner referrals, 13 (16.3%) were other hospital referrals, six (7.5%) were inpatients, six (7.5%) were Emergency Department referrals, and two (2.5%) were readmitted from their homes. No revisions were carried out on asymptomatic patients. Conclusion. Our experience suggests that if there is a robust system in place for self-referral, patients with an ODEP 10A* hip implant can, if asymptomatic, be safely discharged at the time of their first postoperative review. Cite this article: Bone Joint J 2019;101-B:536–539

Objectives. This study investigates the reporting of health-related quality of life (HRQoL) in patients following hip fracture. We compare the relative merits and make recommendations for the use for two methods of measuring HRQoL; (i) including patients who died during follow-up and (ii) including survivors only. Methods. The World Hip Trauma Evaluation has previously reported changes in HRQoL using EuroQol-5D for patients with hip fractures. We performed additional analysis to investigate the effect of including or excluding those patients who died during the first four months of the follow-up period. Results. The dataset included 503 patients, 25 of whom died between 30 days and four months of injury. There was a statistically significant difference in 30-day HRQoL between those alive (mean 0.331 and standard deviation (. sd. ) 0.360) and those dead (mean 0.156 and . sd. 0.421) by four months (independent-samples t-test; p 0.022). The estimated difference of 0.175 in HRQoL (95% confidence interval 0.025 to 0.325) was also highly clinically significant. Conclusion. When reporting HRQoL for patients after a hip fracture, excluding patients who die during follow-up leads to an overestimate of the effects of the intervention or treatment pathway. We would recommend that death-adjusted estimates should be used routinely when reporting HRQoL in this population. Cite this article: N. Parsons, X. L. Griffin, J. Achten, T. J. Chesser, S. E. Lamb, M. L. Costa. Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study. Bone Joint Res 2018;7:1–5

Aims

To investigate the extent of bone development around the scaffold of custom triflange acetabular components (CTACs) over time.

Aims

Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m²) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m²) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach.

Aims

Overall sagittal flexion is restricted in patients who have undergone both lumbar fusion and total hip arthroplasty (THA). However, it is not evident to what extent this movement is restricted in these patients and how this influences quality of life (QoL). The purpose of this study was to determine the extent to which hip-lumbar mobility is decreased in these patients, and how this affects their QoL score.

Aims

Spinopelvic pathology increases the risk for instability following total hip arthroplasty (THA), yet few studies have evaluated how pathology varies with age or sex. The aims of this study were: 1) to report differences in spinopelvic parameters with advancing age and between the sexes; and 2) to determine variation in the prevalence of THA instability risk factors with advancing age.

Aims

The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs.

Aims

Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty.

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims

A revision for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) has a major effect on the patient’s quality of life, including walking capacity. The objective of this case control study was to investigate the histological and ultrastructural changes to the gluteus medius tendon (GMED) in patients revised due to a PJI, and to compare it with revision THAs without infection performed using the same lateral approach.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR.

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Aims

Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI.

Objectives. The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. Patients and Methods. We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. Results. There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. Conclusion. The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important. Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2

Aims

Although CT is considered the benchmark to measure femoral version, 3D biplanar radiography (hipEOS) has recently emerged as a possible alternative with reduced exposure to ionizing radiation and shorter examination time. The aim of our study was to evaluate femoral stem version in postoperative total hip arthroplasty (THA) patients and compare the accuracy of hipEOS to CT. We hypothesize that there will be no significant difference in calculated femoral stem version measurements between the two imaging methods.

Aims

The aim of this study was to compare the mid-term patient-reported outcome, bone remodelling, and migration of a short stem (Collum Femoris Preserving; CFP) with a conventional uncemented stem (Corail).

Aims

Total hip arthroplasties (THAs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is safe practice with comparable outcomes to consultant-performed THA. Our aim was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THA.

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.

Aims

Hip arthroplasty aims to accurately recreate joint biomechanics. Considerable attention has been paid to vertical and horizontal offset, but femoral head centre in the anteroposterior (AP) plane has received little attention. This study investigates the accuracy of restoration of joint centre of rotation in the AP plane.

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.

Aims

Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA.

Aims

The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version?

Aims

The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients.

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

Aims

While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty.

Aims

The aim of this prospective cohort study was to evaluate the early migration of the TriFit cementless proximally coated tapered femoral stem using radiostereometric analysis (RSA).

Aims

Periprosthetic femoral fractures (PPF) are a serious complication of total hip arthroplasty (THA) and are becoming an increasingly common indication for revision arthroplasty with the ageing population. This study aimed to identify potential risk factors for PPF based on an analysis of registry data.

Aims

The processes linking long-term bisphosphonate treatment to atypical fracture remain elusive. To establish a means of exploring this link, we have examined how long-term bisphosphonate treatment with prior ovariectomy modifies femur fracture behaviour and tibia mass and shape in murine bones.

Aims

Femoral revision component subsidence has been identified as predicting early failure in revision hip surgery. This comparative cohort study assessed the potential risk factors of subsidence in two commonly used femoral implant designs.

Aims

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

Aims

Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome.

Aims

Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA).

Aims

Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution.

Aims

We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed.

Aims

Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure.

Aims

It is not known whether change in patient-reported outcome measures (PROMs) over time can be predicted by factors present at surgery, or early follow-up. The aim of this study was to identify factors associated with changes in PROM status between two-year evaluation and medium-term follow-up.

Aims

The aim of this study was to assess the functional gain achieved following hip resurfacing arthroplasty (HRA).

Aims

The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty.

Aims

The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities.

Aims

The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients.

Objectives

The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?

Aims

The aim of this study was to compare the design of the generic OptiStem XTR femoral stem with the established Exeter femoral stem.

Objectives

High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA).

Arthroplasty registries are important for the surveillance of joint replacements and the evaluation of outcome. Independent validation of registry data ensures high quality. The ability for orthopaedic implant retrieval centres to validate registry data is not known. We analysed data from the National Joint Registry for England, Wales and Northern Ireland (NJR) for primary metal-on-metal hip arthroplasties performed between 2003 and 2013. Records were linked to the London Implant Retrieval Centre (RC) for validation. A total of 67 045 procedures on the NJR and 782 revised pairs of components from the RC were included. We were able to link 476 procedures (60.9%) recorded with the RC to the NJR successfully. However, 306 procedures (39.1%) could not be linked. The outcome recorded by the NJR (as either revised, unrevised or death) for a primary procedure was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval linkage and correct assignment of outcome code improved over time. The rates of error for component reference numbers on the NJR were as follows: femoral head category number 14/229 (5.0%); femoral head batch number 13/232 (5.3%); acetabular component category number 2/293 (0.7%) and acetabular component batch number 24/347 (6.5%).

Registry-retrieval linkage provided a novel means for the validation of data, particularly for component fields. This study suggests that NJR reports may underestimate rates of revision for many types of metal-on-metal hip replacement. This is topical given the increasing scope for NJR data. We recommend a system for continuous independent evaluation of the quality and validity of NJR data.

Cite this article: Bone Joint J 2015;97-B:10–18.

Objectives

The primary purpose of this meta-analysis was to determine whether statin usage could reduce the risk of glucocorticoid-related osteonecrosis in animal models.

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery.

We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Cite this article: Bone Joint J 2015;97-B:1345–9

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

Oxidised zirconium (OxZi) has been developed as an alternative bearing surface for femoral heads in total hip arthroplasty (THA). This study has investigated polyethylene wear, functional outcomes and complications, comparing OxZi and cobalt–chrome (CoCr) as part of a three-arm, multicentre randomised controlled trial. Patients undergoing THA from four institutions were prospectively randomised into three groups. Group A received a CoCr femoral head and highly cross-linked polyethylene (XLPE) liner; Group B received an OxZi femoral head and XLPE liner; Group C received an OxZi femoral head and ultra-high molecular weight polyethylene (UHMWPE) liner. At five years, 368 patients had no statistically significant differences in short-form-36 (p = 0.176 mental, p = 0.756 physical), Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.847), pain scores (p = 0.458) or complications. The mean rate of linear wear was 0.028 mm/year (standard deviation (sd) 0.010) for Group A, 0.023 mm/year (sd 0.010) for Group B, and 0.09 mm/year (sd 0.045) for Group C. Penetration was significantly higher in the UHMWPE liner group compared with both XLPE liner groups (p < 0.001) but no significant difference was noted between CoCr and OxZi when articulating with XLPE (p = 0.153). In this, the largest randomised study of this bearing surface, it appears that using a XLPE acetabular liner is more important in reducing THA component wear than the choice of femoral head bearing, at mid-term follow-up. There is a non-significant trend towards lower wear, coupling OxZi rather than CoCr with XLPE but long-term analysis is required to see if this observation changes with time and becomes significant.

Cite this article: Bone Joint J 2015;97-B:883–9.

The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years.

Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14).

Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores.

No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years.

We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems.

Cite this article: Bone Joint J 2015; 97-B:617–22.

We describe the clinical and radiological results of cementless primary total hip replacement (THR) in 25 patients (18 women and seven men; 30 THRs) with severe developmental dysplasia of the hip (DDH). Their mean age at surgery was 47 years (23 to 89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe type IV. Cementless acetabular components with standard polyethylene liners were introduced as close to the level of the true acetabulum as possible. The modular cementless S-ROM femoral component was used with a low resection of the femoral neck.

A total of 21 patients (25 THRs) were available for review at a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified Harris hip score improved from 46 points pre-operatively to 90 at final follow up (p < 0.001).

A total of 15 patients (17 THRs; 57%) underwent revision of the acetabular component at a mean of 14.6 years (7 to 20.8), all for osteolysis. Two patients (two THRs) had symptomatic loosening. No patient underwent femoral revision. Survival with revision of either component for any indication was 81% at 15 years (95% CI 60.1 to 92.3), with 21 patients at risk.

This technique may reduce the need for femoral osteotomy in severe DDH, while providing a good long-term functional result.

Cite this article: Bone Joint J 2014;96-B:1449–54.

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

The lack of a consensus for core health outcomes that should be reported in clinical research has hampered study design and evidence synthesis. We report a United Kingdom consensus for a core outcome set (COS) for clinical trials of patients with a hip fracture.

We adopted a modified nominal group technique to derive consensus on 1) which outcome domains should be measured, and 2) methods of assessment. Participants reflected a diversity of perspectives and experience. They received an evidence synthesis and postal questionnaire in advance of the consensus meeting, and ranked the importance of candidate domains and the relevance and suitability of short-listed measures. During the meeting, pre-meeting source data and questionnaire responses were summarised, followed by facilitated discussion and a final plenary session. A COS was determined using a closed voting system: a 70% consensus was required.

Consensus supported a five-domain COS: mortality, pain, activities of daily living, mobility, and health-related quality of life (HRQL). Single-item measures of mortality and mobility (indoor/outdoor walking status) and a generic multi-item measure of HRQL - the EuroQoL EQ-5D - were recommended. These measures should be included as a minimum in all hip fracture trials. Other outcome measures should be added depending on the particular interventions being studied.

Cite this article: Bone Joint J 2014; 96-B:1016–23.

Recent guidance recommends the use of a well-proven cemented femoral stem for hemiarthroplasty in the management of fractures of the femoral neck, and the Exeter Trauma Stem (ETS) has been suggested as an example of such an implant. The design of this stem was based on the well-proven Exeter Total Hip Replacement stem (ETHRS). This study assessed the surface finish of the ETS in comparison with the ETHRS. Two ETSs and two ETHRSs were examined using a profilometer with a precision of 1 nm and compared with an explanted Exeter Matt stem. The mean roughness average (RA) of the ETSs was approximately ten times higher than that of the ETHRSs (0.235 μm (0.095 to 0.452) versus 0.025 μm (0.011 to 0.059); p < 0.001). The historical Exeter Matt stem roughness measured a mean RA of 0.973 μm (0.658 to 1.159). The change of the polished Exeter stem to a matt surface finish in 1976 resulted in a high stem failure rate. We do not yet know whether the surface differences between ETS and ETHRS will be clinically significant. We propose the inclusion of hemiarthroplasty stems in national joint registries.

Cite this article: Bone Joint J 2013;95-B:173–6.

The purpose of this study was twofold: first, to determine whether the five-year results of hip resurfacing arthroplasty (HRA) in Canada justified the continued use of HRA; and second, to identify whether greater refinement of patient selection was warranted.

This was a retrospective cohort study that involved a review of 2773 HRAs performed between January 2001 and December 2008 at 11 Canadian centres. Cox’s proportional hazards models were used to analyse the predictors of failure of HRA. Kaplan–Meier survival analysis was performed to predict the cumulative survival rate at five years. The factors analysed included age, gender, body mass index, pre-operative hip pathology, surgeon’s experience, surgical approach, implant sizes and implant types. The most common modes of failure were also analysed.

The 2773 HRAs were undertaken in 2450 patients: 2127 in men and 646 in women. The mean age at operation was 50.5 years (sd 8.72; 18 to 82) and mean follow-up was 3.4 years (sd 2.1; 2.0 to 10.1). At the last follow-up a total of 101 HRAs (3.6%) required revision. Using revision for all causes of failure as the endpoint, Kaplan–Meier survival analysis showed a cumulative survival of 96.4% (95% confidence interval (CI) 96.1 to 96.9) at five years. With regard to gender, the five-year overall survival was 97.4% in men (95% CI 97.1 to 97.7) and 93.6% in women (95% CI 92.6 to 94.6). Female gender, smaller femoral components, specific implant types and a diagnosis of childhood hip problems were associated with higher rates of failure. The most common cause of failure was fracture of the femoral neck, followed by loosening of the femoral component.

The failure rates of HRA at five years justify the ongoing use of this technique in men. Female gender is an independent predictor of failure, and a higher failure rate at five years in women leads the authors to recommend this technique only in exceptional circumstances for women.

Cite this article: Bone Joint J 2013;95-B:1044–50.

We conducted a systematic review and meta-analysis of randomised controlled trials comparing cross-linked with conventional polyethylene liners for total hip replacement in order to determine whether these liners reduce rates of wear, radiological evidence of osteolysis and the need for revision. The MEDLINE, EMBASE and COCHRANE databases were searched from their inception to May 2010 for all trials involving the use of cross-linked polyethylene in total hip replacement. Eligibility for inclusion in the review included the random allocation of treatments, the use of cross-linked and conventional polyethylene, and radiological wear as an outcome measure. The pooled mean differences were calculated for bedding-in, linear wear rate, three-dimensional linear wear rate, volumetric wear rate and total linear wear. Pooled risk ratios were calculated for radiological osteolysis and revision hip replacement. A search of the literature identified 194 potential studies, of which 12 met the inclusion criteria. All reported a significant reduction in radiological wear for cross-linked polyethylene.

The pooled mean differences for linear rate of wear, three-dimensional linear rate of wear, volumetric wear rate and total linear wear were all significantly reduced for cross-linked polyethylene. The risk ratio for radiological osteolysis was 0.40 (95% confidence interval 0.27 to 0.58; I² = 0%), favouring cross-linked polyethylene. The follow-up was not long enough to show a difference in the need for revision surgery.

The differential diagnosis of the painful total hip arthroplasty (resurfacing or total hip) includes infection, failure of fixation (loosening), tendinitis, bursitis, synovitis, adverse local tissue reaction (ALTR) to cobalt-chromium alloys, and non-hip issues, such as spinal disorders, hernia, gynecologic, and other pelvic pain. Assuming that the hip is the source of pain, the first level question is prosthetic or non-prosthetic pain generator? The second level prosthetic question is septic or aseptic? The third level question (aseptic hips) is well-fixed or loose? ALTR is best diagnosed by cross-sectional imaging. Successful treatment is dependent on correct identification and elimination of the pain generator. Treatment recommendations for ALTR and taper corrosion are evolving.

We reviewed the initial post-operative radiographs of the Trident acetabulum and identified a problem with seating of the metal-backed ceramic liner. We identified 117 hips in 113 patients who had undergone primary total hip replacement using the Trident shell with a metal-backed alumina liner. Of these, 19 (16.4%) were noted to have incomplete seating of the liner, as judged by plain anteroposterior and lateral radiographs. One case of complete liner dissociation necessitating early revision was not included in the prevalence figures. One mis-seated liner was revised in the early post-operative period and two that were initially incompletely seated were found on follow-up radiographs to have become correctly seated. There may be technical issues with regard to the implanting of this prosthesis of which surgeons should be aware. However, there is the distinct possibility that the Trident shell deforms upon implantation, thereby preventing complete seating of the liner.

In this paper, we will consider the current role of metal-on-metal bearings by looking at three subtypes of MoM hip arthroplasty separately: Hip resurfacing, large head (> 36 mm) MoM THA and MoM THA with traditional femoral head sizes.

Between December 2004 and June 2006, 136 patients (156 total hip replacements), were sent from the waiting list of the Cardiff Vale NHS Trust to the NHS Treatment Centre, Weston-super-Mare, in an attempt to reduce the waiting time for total hip replacement. Because of concerns about their outcome, each patient was contacted and invited to attend a review appointment with a consultant specialising in hip and revision hip replacement.

A total of 98 patients (113 hips) were reviewed after a mean of 23 months (11 to 30). There were 104 cemented hips, seven hybrid and two cementless. An acetabular inclination of > 55° was seen in 18 (16%). Radiolucent lines around the acetabular component were seen in 76 (67%). The femoral component was in more than 4° of varus in 47 (42%). The medial floor had been breached in 13 (12%) and there was a leg-length discrepancy of more than 1 cm in ten (9%). There were three dislocations, one femoral fracture, one pulmonary embolus, one deep infection and two superficial wound infections.

To date, 13% (15 hips) have been revised and a further 4% (five hips) await revision, mostly for a painful loose acetabular component. The revision rate far exceeds the 0.5% five-year failure rate reported in the Swedish Registry for the components used. This initiative and the consequent need for correction of the problems created, has significantly increased the workload of our unit.

The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service.

We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented.

The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.

Despite excellent results, the use of cemented total hip replacement (THR) is declining. This retrospective cohort study records survival time to revision following primary cemented THR using the most common combination of components that accounted for almost a quarter of all cemented THRs, exploring risk factors independently associated with failure. All patients with osteoarthritis who had an Exeter V40/Contemporary THR (Stryker) implanted before 31 December 2010 and recorded in the National Joint Registry for England and Wales were included in the analysis. Cox’s proportional hazard models were used to analyse the extent to which risk of revision was related to patient, surgeon and implant covariates, with a significance threshold of p < 0.01. A total of 34 721 THRs were included in the study. The overall seven-year rate of revision for any reason was 1.70% (99% confidence interval (CI) 1.28 to 2.12). In the final adjusted model the risk of revision was significantly higher in THRs with the Contemporary hooded component (hazard ratio (HR) 1.88, p < 0.001) than with the flanged version, and in smaller head sizes (< 28 mm) compared with 28 mm diameter heads (HR 1.50, p = 0.005). The seven-year revision rate was 1.16% (99% CI 0.69 to 1.63) with a 28 mm diameter head and flanged component. The overall risk of revision was independent of age, gender, American Society of Anesthesiologists grade, body mass index, surgeon volume, surgical approach, brand of cement/presence of antibiotic, femoral head material (stainless steel/alumina) and stem taper size/offset. However, the risk of revision for dislocation was significantly higher with a ‘plus’ offset head (HR 2.05, p = 0.003) and a hooded acetabular component (HR 2.34, p < 0.001).

In summary, we found that there were significant differences in failure between different designs of acetabular component and sizes of femoral head after adjustment for a range of covariates.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

We have compared four computer-assisted methods to measure penetration of the femoral head into the acetabular component in total hip replacement. These were the Martell Hip Analysis suite 7.14, Rogan HyperOrtho, Rogan View Pro-X and Roman v1.70. The images used for the investigation comprised 24 anteroposterior digital radiographs and 24 conventional acetate radiographs which were scanned to provide digital images. These radiographs were acquired from 24 patients with an uncemented total hip replacement with a follow-up of approximately eight years (mean 8.1; 6.3 to 9.1). Each image was measured twice by two blinded observers. The mean annual rates of penetration of the femoral head measured in the eight-year single image analysis were: Martell, 0.24 (SD 0.19); HyperOrtho, 0.12 (SD 0.08); View Pro-X, 0.12 (SD 0.06); Roman, 0.12 (SD 0.07). In paired analysis of the six-month and eight-year radiographs: Martell, 0.35 (SD 0.22); HyperOrtho, 0.15 (SD 0.13); View Pro-X, 0.11 (SD 0.06); Roman, 0.11 (SD 0.07). The intra- and inter-observer variability for the paired analysis was best for View Pro-X and Roman software, with intraclass correlations of 0.97, 0.87 and 0.96, 0.87, respectively, and worst for HyperOrtho and Martell, with intraclass correlations of 0.46, 0.13 and 0.33, 0.39, respectively.

The Roman method proved the most precise and the most easy to use in clinical practice and the software is available free of charge. The Martell method showed the lowest precision, indicating a problem with its edge detection algorithm on digital images.

Persistent groin pain after seemingly successful total hip replacement (THR) appears to have become more common. Recent studies have indicated a high incidence after metal-on-polyethylene and metal-on-metal conventional THR and it has been documented in up to 18% of patients after metal-on-metal resurfacing. There are many causes, including acetabular loosening, stress fracture, and iliopsoas tendonitis and impingement. The evaluation of this problem requires a careful history and examination, plain radiographs and an algorithmic approach to special diagnostic imaging and tests. Non-operative treatment is not usually successful. Specific operative treatment depending on the cause of the pain usually involves revision of the acetabular component, iliopsoas tenotomy or other procedures, and is usually successful. Here, an appropriate algorithm is described.

Modern metal-on-metal hip resurfacing has been widely performed in the United Kingdom for over a decade. However, the literature reports conflicting views of the benefits: excellent medium- to long-term results with some brands in specific subgroups, but high failure rates and local soft-tissue reactions in others. The National Joint Registry for England and Wales (NJR) has collected data on all hip resurfacings performed since 2003. This retrospective cohort study recorded survival time to revision from a resurfacing procedure, exploring risk factors independently associated with failure. All patients with a primary diagnosis of osteoarthritis who underwent resurfacing between 2003 and 2010 were included in the analyses. Cox’s proportional hazard models were used to analyse the extent to which the risk of revision was related to patient, surgeon and implant covariates.

A total of 27 971 hip resurfacings were performed during the study period, of which 1003 (3.59%) underwent revision surgery. In the final adjusted model, we found that women were at greater risk of revision than men (hazard ratio (HR) = 1.30, p = 0.007), but the risk of revision was independent of age. Of the implant-specific predictors, five brands had a significantly greater risk of revision than the Birmingham Hip Resurfacing (BHR) (ASR: HR = 2.82, p < 0.001, Conserve: HR = 2.03, p < 0.001, Cormet: HR = 1.43, p = 0.001, Durom: HR = 1.67, p < 0.001, Recap: HR = 1.58, p = 0.007). Smaller femoral head components were also significantly more likely to require revision (≤ 44 mm: HR = 2.14, p < 0.001, 45 to 47 mm: HR = 1.48, p = 0.001) than medium or large heads, as were operations performed by low-volume surgeons (HR = 1.36, p <  0.001). Once these influences had been removed, in 4873 male patients < 60 years old undergoing resurfacing with a BHR, the five-year estimated risk of revision was 1.59%.

In summary, after adjustment for a range of covariates we found that there were significant differences in the rate of failure between brands and component sizes. Younger male patients had good five-year implant survival when the BHR was used.

We reviewed 123 second-generation uncemented total hip replacements performed on 115 patients by a single surgeon between 1993 and 1994. The acetabular component used in all cases was a fully porous-coated threaded hemispheric titanium shell (T-Tap ST) with a calcium ion stearate-free, isostatically compression-moulded polyethylene liner. The titanium femoral component used was a Taperloc with a reduced distal stem. No patient was lost to follow-up. Complete clinical and radiological follow-up was obtained for all 123 hips at a mean of 14 years (12 to 16). One femoral component was revised after a fracture, and three acetabular components for aseptic loosening. No additional femoral or acetabular components were judged loose by radiological criteria. Mild proximal femoral osteolysis was identified in two hips and minor acetabular osteolysis was present in four. The mean rate of penetration of the femoral head was 0.036 mm/year (0.000 to 0.227).

These findings suggest that refinements in component design may be associated with excellent long-term fixation in cementless primary total hip replacement.

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction.

In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

We report the minimum five-year follow-up of 352 primary total hip replacements using the uncemented hydroxyapatite-coated ANCA-Fit femoral component with a modular neck and head. The series comprised 319 patients (212 men, 107 women) with a mean age at operation of 64.4 years (28 to 97). The principal diagnosis was osteoarthritis. A total of 18 patients (21 hips) died before their follow-up at five years, nine patients (11 hips) were lost to follow-up, and four (four hips) declined further follow-up. Patient-reported outcomes have been recorded for 288 patients (316 hips).

Their mean Oxford Hip Score improved significantly from 41 points (16 to 57) pre-operatively to 20 points (12 to 44) at five-year follow-up. Radiological assessment showed good bony stability in 98% of implants. There were two cases of aseptic loosening of the femoral component. There were no clinical or radiological complications related to modularity. In our series we did not see the high rate of intra-operative fracture previously reported for this implant.

This medium-term follow-up study demonstrates that the clinical outcome of the ANCA-Fit femoral component is, to date, comparable with that of other metaphyseal loading femoral components.

We undertook a randomised controlled trial to compare the outcomes of skin adhesive and staples for skin closure in total hip replacement. The primary outcome was the cosmetic appearance of the scar at three months using a surgeon-rated visual analogue scale. In all, 90 patients were randomised to skin closure using either skin adhesive (n = 45) or staples (n = 45). Data on demographics, surgical details, infection and oozing were collected during the in-patient stay. Further data on complications, patient satisfaction and evaluation of cosmesis were collected at three-month follow-up, and a photograph of the scar was taken. An orthopaedic and a plastic surgeon independently evaluated the cosmetic appearance of the scars from the photographs. No significant difference was found between groups in the cosmetic appearance of scars at three months (p = 0.172), the occurrence of complications (p = 0.3), or patient satisfaction (p = 0.42). Staples were quicker and easier to use than skin adhesive and also less expensive. Skin adhesive and surgical staples are both effective skin closure methods in total hip replacement.

Migration of the acetabular component may give rise to oval-shaped bone defects in the acetabulum. The oblong implant is designed to fill these defects and achieve a stable cementless anchorage with no significant bone loss. We prospectively reviewed 133 oblong long oblique revision components at a mean follow-up of 9.74 years (0.6 to 14). All had been used in revisions for defects of type IIB to IIIB according to Paprosky. Aseptic loosening was the reason for revision in 11 cases (8.3%) and deep infection in seven (5.3%). The probability of implant survival over a 12-year follow-up estimated by the Kaplan-Meier method gave a survival rate of 0.85% respectively 0.90% when deep infection was excluded as the endpoint.

Our study supports the use of these components in defects from IIB to IIIA. The main precondition for success is direct contact of more than half of the surface of the implant with the host acetabular bone.

We report the clinical and radiological outcome at ten years of 104 primary total hip replacements (100 patients) using the Metasul metal-on-metal bearing. Of these, 52 had a cemented Stuehmer-Weber polyethylene acetabular component with a Metasul bearing and 52 had an uncemented Allofit acetabular component with a Metasul liner. A total of 15 patients (16 hips) died before their follow-up at ten years and three were lost to follow-up. The study group therefore comprised 82 patients (85 hips).

The mean Oxford score at ten years was 20.7 (12 to 42). Six of 85 hips required revision surgery. One was performed because of infection, one for aseptic loosening of the acetabular component and four because of unexplained pain. Histological examination showed an aseptic lymphocytic vasculitis associated lesion-type tissue response in two of these. Continued follow-up is advocated in order to monitor the long-term performance of the Metasul bearing and tissue responses to metal debris.

The National Institute for Clinical Excellence (NICE) published the guidelines on the selection of prostheses for primary hip replacement in 2000. They supported the use of cemented hip prostheses to the exclusion of uncemented and hybrid implants. The information from the Trent (and Wales) Regional Arthroplasty Study has been examined to identify retrospectively the types of hip prostheses used between 1990 and 2005, and to assess the impact that the guidelines have had on orthopaedic practice.

The results show that the publication of the NICE guidelines has had little impact on clinical practice, with the use of uncemented prostheses increasing from 6.7% (137) in 2001 to 19.2% (632) in 2005. The use of hybrid prostheses has more than doubled from 8.8% (181) to 22% (722) of all hips implanted in the same period. The recommendations made by NICE are not being followed, which calls into question their value.

The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent gradual closed reduction using the Petit-Morel method. A pelvic osteotomy was required in 43 hips (91.5%). The patients whose hips did not require pelvic osteotomy were among the youngest. The mean age at final follow-up was 16.1 years (11.3 to 32). The mean follow-up was 14.3 years (10 to 30).

At the latest follow-up, 44 hips (93.6%) were graded as excellent or good according to the Severin classification. Closed reduction failed in only two hips (4.3%) which then required open reduction. Mild avascular necrosis was observed in one (2.1%).

The accuracy of the reduction and associated low complication rate justify the use of the Petit-Morel technique as the treatment of choice for developmental dysplasia of the hip in patients aged between one and five years.

We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months.

The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained.

Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip.

We determined the effect of the surgical approach on perfusion of the femoral head during hip resurfacing arthroplasty by measuring the concentration of cefuroxime in bone samples from the femoral head. A total of 20 operations were performed through either a transgluteal or an extended posterolateral approach.

The concentration of cefuroxime in bone was significantly greater when using the transgluteal approach (mean 15.7 mg/kg; 95% confidence interval 12.3 to 19.1) compared with that using the posterolateral approach (mean 5.6 mg/kg; 95% confidence interval 3.5 to 7.8; p < 0.001). In one patient, who had the operation through a posterolateral approach, cefuroxime was undetectable.

Using cefuroxime as an indirect measure of blood flow, the posterolateral approach was found to be associated with a significant reduction in the blood supply to the femoral head during resurfacing arthroplasty compared with the transgluteal approach.

The Morscher-Spotorno (MS-30) femoral stem is a stainless-steel, straight, three-dimensionally tapered, collarless implant for cemented fixation in total hip replacement.

We report the results at ten years of a consecutive series of 124 total hip replacements in 121 patients with the matt-surfaced MS-30 stem and an alumina ceramic head of 28-mm diameter. All the stems were fixed with Palacos bone cement with gentamicin using a modern cementing technique. They were combined with an uncemented, press-fit cup. The mean period of observation was 10.2 years (8.3 to 12.1) and no patient was lost to follow-up. Twenty-seven patients (22%) died with the implant in situ. Nine could only be interviewed by telephone. We included 85 patients with 88 hips in the clinical and radiological follow-up examinations.

None of the stems or cups had been revised. The Harris hip score was excellent or good in 97% (85 hips) and moderate in 3% (three hips). Radiologically, six hips (6.8%) had osteolysis adjacent to the stem, mostly in Gruen zone 7. Twenty (22.7%) showed one or more radiolucent lines. Twenty-two stems (25%) had subsided by 2 mm to 5 mm. In these cases two showed osteolysis (9.1%) with subsidence and four without (6.1%). Radiolucent lines were seen in seven with migration (31.8%) and in 13 without (19.7%). No infections and no acetabular osteolysis were observed.

The clinical results were excellent with survivorship after ten years of 100% and only a slightly statistically non-significant higher rate of osteolysis and radiolucency in cases of subsidence.