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

Aims. This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. Methods. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology. Results. The mean follow-up was 96 months (67 to 139). The SHV, mHHS, WOMAC, and Tegner scores significantly improved (p < 0.001) at last follow-up. According to SHV and mHHS, there were three hips (7%) with poor results (SHV < 70), three (7%) with a fair score (70 to 79), eight (19%) with good results (80 to 89), and 28 (67%) who scored excellent (> 90) at the last follow-up. There were 11 subsequent operations: nine implant removals due to local irritation, one resection of postoperative heterotopic ossification, and one hip arthroscopy for intra-articular adhesions. No hips were converted to total hip arthroplasty at last follow-up. The presence of preoperative labral lesions or LT lesions did not influence any PROMs at last follow-up. From the three hips that had poor PROMs, two have developed severe osteoarthritis (> Tönnis II), presumably due to surgical overcorrection (postoperative AI < -10°). Conclusion. PAO is reliable in treating BHD with favourable mid-term outcomes. Concomitant LT and labral lesions did not negatively influence outcomes in our cohort. Technical accuracy with avoidance of overcorrection is essential in achieving successful outcomes. Cite this article: Bone Joint J 2023;105-B(7):735–742

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. Patients and Methods. Patients undergoing Birmingham Hip Resurfacing completed the Veteran’s Rand 36 (VR-36), modified Harris Hip Score (mHHS), Tegner Activity Score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at two years and a minimum of three years. A change in score was assessed against minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds. Binary logistic regression was used to assess the relationship between patient factors and deterioration in PASS status between follow-ups. Results. Overall, 18% of patients reported reductions in mHHS total score exceeding MCID, and 21% reported similar reductions for WOMAC function scores. Nonetheless, almost all patients remained above PASS thresholds for WOMAC function (98%) and mHHS (93%). Overall, 66% of patients with mHHS scores < PASS at two years reported scores > PASS at latest follow-up. Conversely, 6% of patients deteriorated from > PASS to < PASS between follow-ups. Multivariable modelling indicated body mass index (BMI) > 27 kg/m. 2. , VR-36 Physical Component Score (PCS) < 51, VR-36 Mental Component Score (MCS) > 55, mHHS < 84 at two years, female sex, and bone graft use predicted these deteriorating patients with 79% accuracy and an area under the curve (AUC) of 0.84. Conclusion. Due to largely acceptable results at a later follow-up, extensive monitoring of multiple PROMs is not recommended for Birmingham Hip Resurfacing patients unless they report borderline or unacceptable hip function at two years, are female, are overweight, or received a bone graft during surgery. Cite this article: Bone Joint J 2019;101-B:1431–1437

Aims. To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures. Methods. The study was registered at clinicaltrials.gov (ID: NCT03161990) on 15 May 2017. Patients treated with a single DAIR procedure for deep infection through the same operative approach as their primary THA (either the transgluteal or the posterior approach) were identified in the Norwegian Arthroplasty Register and given a questionnaire. Median follow-up after DAIR by questionnaire was 5.5 years in the transgluteal group (n = 87) and 2.5 years in the posterior approach group (n = 102). Results. Patients in the posterior approach group were less likely to limp after the DAIR procedure (17% vs 36% limped all the time; p = 0.005), had a higher mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (80 vs 71; p = 0.013), and were more likely to achieve a patient acceptable symptom state for the WOMAC function score (76% vs 55%; p = 0.002). In a multivariable analysis, the point estimate for the increase in WOMAC function score using the posterior approach was 10.2 (95% CI 3.1 to 17.2; p = 0.005), which is above the minimal clinically important improvement. The patients in the posterior approach group also reported better mean HRQoL scores and were more likely to be satisfied with their hip arthroplasty (77% vs 55%; p = 0.001). Conclusion. In patients treated with a single, successful DAIR procedure for deep infection of a primary THA, the use of the posterior approach in both primary surgery and DAIR was associated with less limping, better functional outcome, better HRQoL, and higher patient satisfaction compared with cases where both were performed using the transgluteal approach. The observed differences in functional outcome and patient satisfaction were clinically relevant. Cite this article: Bone Joint J 2020;102-B(12):1662–1669

Aims. This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA). Methods. Patients undergoing primary THA were recruited from four institutions and prospectively allocated to the following treatment groups: Group A, CoCr femoral head with XLPE liner; Group B, OxZr femoral head with XLPE liner; and Group C, OxZr femoral head with UHMWPE liner. All study patients and assessors recording outcomes were blinded to the treatment groups. The outcomes of 262 study patients were analyzed at ten years’ follow-up. Results. Patients in Group C were associated with increased mean liner wear rates compared to patients in Group A (0.133 mm/yr (SD 0.21) vs 0.031 mm/yr (SD 0.07), respectively; p < 0.001) and Group B (0.133 mm/yr (SD 0.21) vs 0.022 mm/yr (SD 0.05), respectively; p < 0.001) at ten years’ follow-up. Patients in Group C were also associated with increased risk of osteolysis and aseptic loosening requiring revision surgery, compared with patients in Group A (7/133 vs 0/133, respectively; p = 0.007) and Group B (7/133 vs 0/135, respectively; p = 0.007). There was a non-statistically significant trend towards increased mean liner wear rates in Group A compared with Group B (0.031 mm/yr (SD 0.07) vs 0.022 mm/yr (SD 0.05), respectively; p = 0.128). All three groups were statistically comparable preoperatively and at ten years’ follow-up when measuring normalized Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.410), 36-Item Short Form Health Survey (p = 0.465 mental, p = 0.713 physical), and pain scale scores (p = 0.451). Conclusion. The use of UHMWPE was associated with progressively increased annual liner wear rates after THA compared to XLPE. At ten years’ follow-up, the group receiving UHMWPE demonstrated an increased incidence of osteolysis and aseptic loosening requiring revision surgery compared to XLPE. Femoral heads composed of OxZr were associated with trend towards reduced wear rates compared to CoCr, but this did not reach statistical significance and did not translate to any differences in osteolysis, functional outcomes, or revision surgery between the two femoral head components. Cite this article: Bone Joint J 2022;104-B(7):833–843

Aims. The aim of this study was to evaluate blood metal ion levels, leucocyte profiles, and serum cytokines in patients with a total hip arthroplasty (THA) involving modular dual-mobility components. Patients and Methods. A total of 39 patients were recruited, with clinical follow-up of up to two years. Outcome was assessed using the Harris Hip Score (HHS, the 12-Item Short-Form Health Survey (SF-12), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a visual analogue scale (VAS) for pain. Blood concentrations of cobalt (Co), chromium (Cr), and serum cytokines were measured. Subpopulations of leucocytes were analyzed by flow cytometry. Results. The clinical performance was good. Blood Co levels (ref 1.0 µg/l) were mildly elevated in seven patients at three months, and two patients at two years’ follow-up. The preoperative Cr levels were normal except for one patient with a detectable Cr (1.2 µg/l). Cr levels were detectable in three patients at three months, two patients at one year, and three patients at two years’ follow-up. No patients had symptoms suggestive of failure. Although flow cytometry showed constant circulating leucocyte profiles, there was a significant reduction of serum interleukin (IL)-4, IL-5, and interferon gamma (IFNγ) postoperatively compared with the preoperative levels (p < 0.05). Conclusion. These results suggest that THA using modular dual-mobility components is safe. This allows an opportunity to use a large femoral head and a thick polyethylene bearing surface, which is especially useful in revision procedures or high-risk situations when added stability is required. Cite this article: Bone Joint J 2019;101-B:1035–1041

Aims. The primary aim of our study was to assess the influence of age on hip-specific outcome following total hip arthroplasty (THA). Secondary aims were to assess health-related quality of life (HRQoL) and level of activity according to age. Methods. A prospective cohort study was conducted. All patients were fitted with an Exeter stem with a 32 mm head on highly cross-linked polyethylene (X3RimFit) cemented acetabulum. Patients were recruited into three age groups: < 65 years, 65 to 74 years, and ≥ 75 years, and assessed preoperatively and at three, 12, 24, and 60 months postoperatively. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and Hip disability and Osteoarthritis Outcome Score (HOOS), were used to assess hip-specific outcome. EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and 36-Item Short Form Survey (SF-36) scores were used to assess HRQoL. The Lower Extremity Activity Scale (LEAS) and Timed Up and Go (TUG) were used to assess level of activity. Results. There were no significant (p > 0.05) differences in the WOMAC scores, HSS, HOOS, or EQ-5D-5L at any postoperative timepoint between the age groups. Patients aged ≥ 75 years had significantly lower physical function (p ≤ 0.010) and physical role (p ≤ 0.047) SF-36 scores at 12, 24, and 60 months, but were equal to that expect of an age-matched population. No differences according to age were observed for the other six domains of the SF-36 (p > 0.060). The ≥ 75 years group had a lower LEAS (p < 0.001) and longer TUG test times (p ≤ 0.032) compared to the < 65 years group, but older age groups had significant (p < 0.001) improvement relative to their preoperative baseline measures. Conclusion. Age did not influence postoperative hip-specific outcome or HRQoL (according to the EQ-5D) following THA. Despite a significant improvement, older patients had lower postoperative activity levels compared to younger patients, but this may be reflective of the overall physical effect of ageing. Cite this article: Bone Jt Open 2022;3(9):692–700

Aims. Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components. Methods. From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment. Results. A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group. Conclusion. Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J 2021;103-B(7):1215–1221

Aims. We investigated the long-term performance of the Tripolar Trident acetabular component used for recurrent dislocation in revision total hip arthroplasty. We assessed: 1) rate of re-dislocation; 2) incidence of complications requiring re-operation; and 3) Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain and functional scores. Patients and Methods. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1994 and 2008. All patients had undergone revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 after more than three revisions. A total of 75 hips (73 patients) were treated with Tripolar liners due to recurrent instability with abductor deficiency, In addition, six patients had associated cerebral palsy, four had poliomyelitis, two had multiple sclerosis, two had spina bifida, two had spondyloepiphyseal dysplasia, one had previous reversal of an arthrodesis, and 21 had proximal femoral replacements. The mean age of patients at time of Tripolar insertions was 72 years (53 to 89); there were 69 female patients (two bilateral) and 42 male patients. All patients were followed up for a mean of 15 years (10 to 24). Overall, 55 patients (57 hips) died between April 2011 and February 2018, at a mean of 167 months (122 to 217) following their tripolar liner implantation. We extracted demographics, implant data, rate of dislocations, and incidence of other complications. Results. At ten years, the Kaplan–Meier survivorship for dislocation was 95.6% (95% confidence interval (CI) 90 to 98), with 101 patients at risk. At 20 years, the survivorship for dislocation was 90.6% (95% CI 81.0 to 95.5), with one patient at risk. Eight patients (7.2%) had a dislocation of their constrained liners. At ten years, the survival to any event was 89.4% (95% CI 82 to 93.8), with 96 patients at risk. At 20 years, the survival to any event was 82.5% (95% CI 71.9 to 89.3), with one patient at risk. Five hips (4.4%) had deep infection. Two patients (1.8%) developed dissociated constraining rings with pain but without dislocation, which required re-operation. Two patients (1.8%) had periprosthetic femoral fractures, without dislocation, that were treated by revision stems along with exchange of the well-functioning constrained liners. Conclusion. Constrained tripolar liners used at revision hip arthroplasty provided favourable results in the long term for treatment of recurrent dislocation and for patients at high risk of dislocation. Cite this article: Bone Joint J 2019;101-B(6 Supple B):123–126

Aims. Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. Methods. In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). Results. The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. Conclusion. THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. Level of evidence IV. Femoral shortening useful in conditions other than DDH and septic sequelae. Restoration of hip centre combined with offset to be planned and ensured

Juvenile idiopathic arthritis (JIA) is a chronic disease of childhood; it causes joint damage which may require surgical intervention, often in the young adult. The aim of this study was to describe the long-term outcome and survival of hip replacement in a group of adult patients with JIA and to determine predictors of survival for the prosthesis. In this retrospective comparative study patients were identified from the database of a regional specialist adult JIA clinic. This documented a series of 47 hip replacements performed in 25 adult patients with JIA. Surgery was performed at a mean age of 27 years (11 to 47), with a mean follow-up of 19 years (2 to 36). The mean Western Ontario and McMaster Universities osteoarthritis index questionnaire (WOMAC) score at the last follow-up was 53 (19 to 96) and the mean Health Assessment Questionnaire score was 2.25 (0 to 3). The mean pain component of the WOMAC score (60 (20 to 100)) was significantly higher than the mean functional component score (46 (0 to 97)) (p = 0.02). Kaplan-Meier survival analysis revealed a survival probability of 46.6% (95% confidence interval 37.5 to 55.7) at 19 years, with a trend towards enhanced survival with the use of a cemented acetabular component and a cementless femoral component. This was not, however, statistically significant (acetabular component, p = 0.76, femoral component, p = 0.45). Cox’s proportional hazards regression analysis showed an implant survival rate of 54.9% at 19 years at the mean of covariates. Survival of the prosthesis was significantly poorer (p = 0.001) in patients who had been taking long-term corticosteroids and significantly better (p = 0.02) in patients on methotrexate

We reviewed the results of 84 total hip replacements performed with a short metaphyseal-fitting anatomical cementless femoral component in 84 unselected consecutive patients with a mean age of 78.9 years (70 to 88). The mean follow-up was 4.6 years (4 to 5). The mean pre-operative Harris hip score was 26 points (0 to 56), which improved to 89 (61 to 100) at the final follow-up. No patient had thigh pain. The mean pre-operative Western Ontario and McMaster Universities osteoarthritis index score was 61 points (48 to 75), which improved to 21 (6 to 46). The mean University of California, Los Angeles activity score was 5.5 points (3 to 7) at the final follow-up. Osseointegration was seen in all femoral and acetabular components. All hips had grade 1 stress shielding of the proximal femur. No acetabular or femoral osteolysis was identified. These results demonstrate that a short metaphyseal-fitting femoral component achieves optimal fixation without diaphyseal anchorage in elderly patients

Objectives. Our primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age. Patients and Methods. A prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones. Results. Mean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02). Conclusion. Exeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups. Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019;8:275–287. DOI: 10.1302/2046-3758.86.BJR-2018-0300.R1

Aims. This study reports the mid-term results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing. Patients and Methods. Of the 276 hips (246 patients) included in this study, 264 (96%) were reviewed at a mean of 67 months (48 to 79) postoperatively. Procedures were performed with a mini posterior approach. Clinical and radiological outcomes were recorded at regular intervals. A noise assessment questionnaire was completed at last follow-up. Results. There were four re-operations (1%) including one early revision for insufficient primary fixation (0.4%). No hip dislocation was reported. The mean University of California, Los Angeles (UCLA) activity score, 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS) score, SF-12 Physical Component Summary (PCS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Forgotten Joint Score (FJS) were 6.6 (2 to 10), 52.8 (25.5 to 65.7), 53.0 (27.2 to 66.5), 7.7 (0 to 63), and 88.5 (23 to 100), respectively. No signs of loosening or osteolysis were observed on radiological review. The incidence of squeaking was 23% (n = 51/225). Squeaking was significantly associated with larger head diameter (p < 0.001), younger age (p < 0.001), higher SF-12 PCS (p < 0.001), and UCLA scores (p < 0.001). Squeaking did not affect patient satisfaction, with 100% of the squeaking hips satisfied with the surgery. Conclusion. LDH CoC THAs have demonstrated excellent functional outcomes at medium-term follow-up, with very low revision rate and no dislocations. The high incidence of squeaking did not affect patient satisfaction or function. LDH CoC with a monoblock acetabular component has the potential to provide long term implant survivorship with unrestricted activity, while avoiding implant impingement, liner fracture at insertion, and hip instability. Cite this article: Bone Joint J 2018;100-B:1434–41

This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult. The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70). No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d’Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone. The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d’Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery

We evaluated the outcome of primary total hip replacement (THR) in 3290 patients with the primary diagnosis of osteoarthritis at a minimum follow-up of two years. They were stratified into categories of body mass index (BMI) based on the World Health Organisation classification of obesity. Statistical analysis was carried out to determine if there was a difference in the post-operative Western Ontario and McMaster Universities osteoarthritis index, the Harris hip score and the Short-Form-12 outcome based on the BMI. While the pre- and post-operative scores were lower for the group classified as morbidly obese, the overall change in outcome scores suggested an equal if not greater improvement compared with the non-morbidly obese patients. The overall survivorship and rate of complications were similar in the BMI groups although there was a slightly higher rate of revision for sepsis in the morbidly obese group. Morbid obesity does not affect the post-operative outcome after THR, with the possible exception of a marginally increased rate of infection. Therefore withholding surgery based on the BMI is not justified

We evaluated 31 patients with bilateral dysplastic hips who had undergone periacetabular osteotomy for early (Tönnis grade 0 or 1) or moderate (Tönnis grade 2) osteoarthritis in one hip and total hip replacement for advanced (Tönnis grade 3) osteoarthritis in the other. At a mean follow-up of 5.5 years (2 to 9) after periacetabular osteotomy and 6.7 years (3 to 10) after total hip replacement, there was no difference in the functional outcome in hips undergoing osteotomy for early or moderate osteoarthritis and those with a total hip replacement, as determined by the Merle d’Aubigné and Postel score and the Western Ontario and McMaster Universities osteoarthritis index. More patients preferred the spherical periacetabular osteotomy to total hip replacement (53% vs 23%; p = 0.029). Osteoarthritis secondary to hip dysplasia is often progressive. Given the results, timely correction of dysplasia by periacetabular osteotomy should be considered whenever possible in young patients since this could produce a favourable outcome which is comparable with that of total hip replacement

Our aim was to define the minimum set of patient-reported outcome measures which are required to assess health status after total hip replacement (THR). In 114 patients, we compared the pre-operative characteristics and sensitivity to change of the Oxford hip score (OHS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), the SF-36, the SF-12 (derived from the SF-36), and the Euroqol questionnaire (EQ-5D). At one year after operation, very large effect sizes were found for the disease-specific measures, the physical domains of the SF-12, SF-36 and the EQ-5D. index. (1.3 to 3.0). Patients in Charnley class A showed more change in the OHS, WOMAC pain and function, the physical domains of the SF-36 and the EQ-5D. vas. (p < 0.05) compared with those in the Charnley B and C group. In this group, the effect size for the OHS more than doubled the effect sizes of WOMAC pain and physical function. We found high correlations and correlations of change between the OHS, the WOMAC, the physical domains of the SF-12 and the SF-36 and EQ-5D. index. The SF-36 and EQ-5D scores at one year after operation approached those of the general population. Furthermore, we found a binomial distribution of the pre-operative EQ-5D. index. score and a pre-operative discrepancy and post-operative agreement between the EQ-5D. vas. and EQ-5D. index. . We recommend the use of the OHS and SF-12 in the assessment of THR. The SF-36 may be used in circumstances when smaller changes in health status are investigated, for example in the follow-up of THR. The EQ-5D is useful in situations in which utility values are needed in order to calculate cost-effectiveness or quality-adjusted life years (QALYs), such as in the assessment of new techniques in THR

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).

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.

Aims

Head-taper corrosion is a cause of failure in total hip arthroplasty (THA). Recent reports have described an increasing number of V40 taper failures with adverse local tissue reaction (ALTR). However, the real incidence of V40 taper damage and its cause remain unknown. The aim of this study was to evaluate the long-term incidence of ALTR in a consecutive series of THAs using a V40 taper and identify potentially related factors.

Aims

The aim of this study was to report the implant survival and patient-reported outcome measures (PROMs) in a consecutive series of patients aged less than 50 years at the time of arthroplasty using the Birmingham Hip Resurfacing system (BHR), with a minimum follow-up of ten years.

Aims

The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate.

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

Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction.

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Aims

Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS).

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Aims

Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.

Aims

The purpose of this study was to examine whether leg-length discrepancy (LLD) following unilateral total hip arthroplasty (THA) affects the incidence of contralateral head collapse and subsequent THA in patients with bilateral osteonecrosis, and to determine factors associated with subsequent collapse.

Aims

Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading.

Aims

The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE.

Objectives

The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE).

Aims

The direct anterior (DA) approach has been associated with rapid patient recovery after total hip arthroplasty (THA) but may be associated with more frequent femoral complications including implant loosening. The objective of this study was to determine whether the addition of a collar to the femoral stem affects implant migration, patient activity, and patient function following primary THA using the DA approach.

Aims

The primary aim of this study was to quantify the improvement in patient-reported outcome measures (PROMs) following total hip arthroplasty (THA), as well as the extent of any deterioration through the seven-year follow-up. The secondary aim was to identify predictors of PROM improvement and deterioration.

There have been comparatively few studies of the incidence of osteolysis and the survival of hybrid and cementless total hip replacements (THRs) in patients younger than 50 years of age. We prospectively reviewed 78 patients (109 hips) with a hybrid THR having a mean age of 43.4 years (21 to 50) and 79 patients (110 hips) with a cementless THR with a mean age of 46.8 years (21 to 49). The patients were evaluated clinically using the Harris hip score, the Western Ontario and McMaster Universities (WOMAC) osteoarthritis score and the University of California, Los Angeles (UCLA) activity score. Radiographs and CT scans were assessed for loosening and osteolysis. The mean follow-up was for 18.4 years (16 to 19) in both groups.

The mean post-operative Harris hip scores (91 points versus 90 points), the mean WOMAC scores (11 points versus 13 points) and UCLA activity scores (6.9 points versus 7.1 points) were similar in both groups. The revision rates of the acetabular component (13% versus 16%) and the femoral component (3% versus 4%), and the survival of the acetabular component (87% versus 84%) and the femoral component (97% versus 96%) were similar in both groups.

Although the long-term fixation of the acetabular metallic shell and the cemented and cementless femoral components was outstanding, wear and peri-acetabular osteolysis constitute the major challenges of THR in young patients.

The purpose of this study was to determine patient-reported outcomes of patients with mild to moderate developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) undergoing arthroscopy of the hip in the treatment of chondrolabral pathology. A total of 28 patients with a centre-edge angle between 15° and 19° were identified from an institutional database. Their mean age was 34 years (18 to 53), with 12 female and 16 male patients. All underwent labral treatment and concomitant correction of FAI. There were nine reoperations, with two patients requiring revision arthroscopy, two requiring periacetabular osteotomy and five needing total hip arthroplasty.

Patients who required further major surgery were more likely to be older, male, and to have more severe DDH with a larger alpha angle and decreased joint space.

At a mean follow-up of 42 months (24 to 89), the mean modified Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p < 0.001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to 43; p < 0.001). Median patient satisfaction was 9.0/10 (1 to 10). Patients reported excellent improvement in function following arthroscopy of the hip.

This study shows that with proper patient selection, arthroscopy of the hip can be successful in the young patient with mild to moderate DDH and FAI.

Cite this article: Bone Joint J 2015;97-B:1316–21.

Several factors have been implicated in unsatisfactory results after total hip replacement (THR). We examined whether femoral offset, as measured on digitised post-operative radiographs, was associated with pain after THR. The routine post-operative radiographs of 362 patients (230 women and 132 men, mean age 70.0 years (35.2 to 90.5)) who received primary unilateral THRs of varying designs were measured after calibration. The femoral offset was calculated using the known dimensions of the implants to control for femoral rotation. Femoral offset was categorised into three groups: normal offset (within 5 mm of the height-adjusted femoral offset), low offset and high offset. We determined the associations to the absolute final score and the improvement in the mean Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain subscale scores at three, six, 12 and 24 months, adjusting for confounding variables.

The amount of femoral offset was associated with the mean WOMAC pain subscale score at all points of follow-up, with the low-offset group reporting less WOMAC pain than the normal or high-offset groups (six months: 7.01 (sd 11.69) vs 12.26 (sd 15.10) vs 13.10 (sd 16.20), p = 0.006; 12 months: 6.55 (sd 11.09) vs 9.73 (sd 13.76) vs 13.46 (sd 18.39), p = 0.010; 24 months: 5.84 (sd 10.23) vs 9.60 (sd 14.43) vs 13.12 (sd 17.43), p = 0.004). When adjusting for confounding variables, including age and gender, the greatest improvement was seen in the low-offset group, with the normal-offset group demonstrating more improvement than the high-offset group.

Cite this article: Bone Joint J 2014;96-B:36–42.

We reviewed the results at nine to 13 years of 125 total hip replacements in 113 patients using the monoblock uncemented Morscher press-fit acetabular component. The mean age at the time of operation was 56.9 years (36 to 74). The mean clinical follow-up was 11 years (9.7 to 13.5) and the mean radiological follow-up was 9.4 years (7.7 to 13.1). Three hips were revised, one immediately for instability, one for excessive wear and one for deep infection.

No revisions were required for aseptic loosening. A total of eight hips (7.0%) had osteolytic lesions greater than 1 cm, in four around the acetabular component (3.5%). One required bone grafting behind a well-fixed implant. The mean wear rate was 0.11 mm/year (0.06 to 0.78) and was significantly higher in components with a steeper abduction angle.

Kaplan-Meier survival curves at 13 years showed survival of 96.8% (95% confidence interval 90.2 to 99.0) for revision for any cause and of 95.7% (95% confidence interval 88.6 to 98.4) for any acetabular re-operation.

The ideal acetabular component is characterised by reliable, long-term fixation with physiological loading of bone and a low rate of wear. Trabecular metal is a porous construct of tantalum which promotes bony ingrowth, has a modulus of elasticity similar to that of cancellous bone, and should be an excellent material for fixation.

Between 2004 and 2006, 55 patients were randomised to receive either a cemented polyethylene or a monobloc trabecular metal acetabular component with a polyethylene articular surface. We measured the peri-prosthetic bone density around the acetabular components for up to two years using dual-energy x-ray absorptiometry.

We found evidence that the cemented acetabular component loaded the acetabular bone centromedially whereas the trabecular metal monobloc loaded the lateral rim and behaved like a hemispherical rigid metal component with regard to loading of the acetabular bone. We suspect that this was due to the peripheral titanium rim used for the mechanism of insertion.

Despite the increasing interest and subsequent published literature on hip resurfacing arthroplasty, little is known about the prevalence of its complications and in particular the less common modes of failure. The aim of this study was to identify the prevalence of failure of hip resurfacing arthroplasty and to analyse the reasons for it.

From a multi-surgeon series (141 surgeons) of 5000 Birmingham hip resurfacings we have analysed the modes, prevalence, gender differences and times to failure of any hip requiring revision. To date 182 hips have been revised (3.6%). The most common cause for revision was a fracture of the neck of the femur (54 hips, prevalence 1.1%), followed by loosening of the acetabular component (32 hips, 0.6%), collapse of the femoral head/avascular necrosis (30 hips, 0.6%), loosening of the femoral component (19 hips, 0.4%), infection (17 hips, 0.3%), pain with aseptic lymphocytic vascular and associated lesions (ALVAL)/metallosis (15 hips, 0.3%), loosening of both components (five hips, 0.1%), dislocation (five hips, 0.1%) and malposition of the acetabular component (three hips, 0.1%). In two cases the cause of failure was unknown.

Comparing men with women, we found the prevalence of revision to be significantly higher in women (women = 5.7%; men = 2.6%, p < 0.001). When analysing the individual modes of failure women had significantly more revisions for loosening of the acetabular component, dislocation, infection and pain/ALVAL/metallosis (p < 0.001, p = 0.004, p = 0.008, p = 0.01 respectively).

The mean time to failure was 2.9 years (0.003 to 11.0) for all causes, with revision for fracture of the neck of the femur occurring earlier than other causes (mean 1.5 years, 0.02 to 11.0). There was a significantly shorter time to failure in men (mean 2.1 years, 0.4 to 8.7) compared with women (mean 3.6 years, 0.003 to 11.0) (p < 0.001).

Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis.

The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.