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Aims “Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. Methods This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70. Results Overall revision rate was 1.3% (13/1,004). A greater number of revisions were undertaken in those aged over 65 years, but numbers were small and did not reach significance. The majority of revisions were implant-independent. Single component analysis revealed a 99.9% and 99.6% survival for the uncemented cup and femoral component, respectively. Mean patient-reported outcome measures (PROMs) improvement for all ages outperformed the national PROMs and a significantly greater proportion of those aged over 65/69 years reached and maintained a meaningful improvement in their OHS earlier than their younger counterparts (p < 0.05/0.01 respectively). Conclusion This study confirms that this uncemented THA system can be used safely and effectively in patient groups aged over 65 years and those over 69 years, with low complication and revision rates. Cite this article: Bone Jt Open 2021;2(5):293–300.

This study prospectively reports survivorship and radiographic and clinical outcomes following primary elective total hip arthroplasty (THA) using a novel single hemispherical, porous-coated acetabular cup with five different bearing combinations and a minimum of five year follow-up. Continuing post-market release monitoring of this cup, we prospectively enrolled 108 patients (121 THA) between 2009 and 2015. We followed this cohort by examining survivorship, in addition to clinical and radiological outcomes for metal-on-metal (MoM) compared with non-MoM bearing combinations (ceramic-on-ceramic, oxinium-on-polyethylene, ceramic-on-metal, and metal-on-polyethylene). All 108 (121 hips) patients were followed up. Average age at time of surgery was 45.1 years (range 19 to 71 years) of which 42.1% were males. A total of seven (5.8%) cups were revised, all of which were MoM. No osteolysis was observed in any of the patients at the latest visit with a mean follow-up of 9.1 ± 1.7 years (range 4.4–10.7 years). With MoM excluded, survivorship of the cup at five years is 97.8%. Survivorship for MoM implants was 90.0%. Validated hip scores showed significant improvements for all bearing types and no significant difference between groups at latest follow-up (p = 0.614). There was no cup migration with any bearing surface. This cup showed excellent survivorship at five year follow-up, except for patients receiving a MoM articulation. While there were concerns over the early survivorship of this cup, our cohort and joint registry data confirm excellent outcomes.

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts. Cite this article: Bone Joint Open 2020;1-6:198–202.

Purpose: To retrospectively review the safety and efficacy of genicular artery embolization procedures performed at our institution in patients presenting with recurrent knee hemarthrosis following total knee arthroplasty (TKA). Materials and Methods: A total of 13 consecutive patients (average age: 68; range 51-84, 62% female) were identified who underwent 14 genicular artery embolization procedures after presenting with recurrent hemarthrosis after TKA. Patient charts were retrospectively reviewed for demographic information, pre-embolization investigations, and details of embolization procedure including complications, technical success, and clinical success. Each patient had failed initial conservative therapy and all patients had a diagnostic aspiration performed by the referring physician prior to the procedure. The average time between TKA and embolization in our cohort was 21 months. Results: All procedures performed were technically successful, defined as elimination of periprosthetic hypervascular blush. An average of 3.6 genicular vessels were embolized in each patient; 355 to 500 µm polyvinyl alcohol (PVA) particles were used in each case. There were no cases of transient cutaneous ischemia, skin erythema, or skin necrosis. Clinical success was obtained in 85.7% of cases, defined by elimination of the presenting clinical symptoms (knee pain and swelling) during continued follow-up by the referring clinician. Conclusion: Particle embolization is a safe and effective treatment for recurrent hemarthrosis after arthroplasty and our experience suggests that utilizing particle sizes of greater than 300 µm appears to be important in order to avoid cutaneous ischemic complications.

Background Oxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA). Methods Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. “oxidized” AND “zirconium” AND “total” AND “hip” AND “arthroplasty”; b. “oxinium” AND “total” AND “hip” AND “arthroplasty”. The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear. Results The vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants. Conclusion OxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs. Level of Evidence Systematic review and meta-analysis of therapeutic studies I-III.

IntroductionDespite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.MethodsDesign: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1–2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.ResultsPhase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening.ConclusionAn empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

© 2020 Elsevier Inc. Background: This study reports the long-term outcomes of a metaphyseal fit-and-fill cementless femoral component in total hip arthroplasty (THA) with a follow-up of 15-19 years. Methods: We conducted a retrospective review of 376 consecutive THAs (345 patients), using a triple tapered stem performed between 2000 and 2003 with a view to assessing survivorship and radiological and functional outcomes. Images were assessed for initial alignment, terminal osteolysis, or subsidence, while clinical outcomes were assessed using the St Michael's Hip Score. Results: Forty-five (11.9%) hips were lost to follow-up, 20 (5.31%) had died before our 15-year cutoff follow-up, and 4 (1.06%) had declined follow-up early on, leaving 307 hips (81.64%, 276 patients) available for both clinical and radiological follow-up at a minimum of 15 years (range 15-19). The mean age at the time of operation was 49.6 years (range 19-71) and the cohort included 131 (42.67%) male and 145 (47.23%) female patients. Seven stems (2.28%) were revised: 4 due to periprosthetic fractures, 2 for periprosthetic joint infection, and 1 for adverse reaction to metal debris at the trunnion. The St Michael's Hip Score improved from 14.2 (range 9-23) preoperatively to 22.3 (range 13 to 25) at the last documented follow-up (P = .000). Kaplan-Meier survivorship with stem revision for any reason as the end point was 97.70%. Worst-case scenario Kaplan-Meier survivorship, where all lost to follow-up are considered as failures, was 85.3%. No stem was revised for aseptic loosening. Conclusion: This triple tapered stem in THA shows excellent survivorship beyond a minimum of 15 years.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

AimsWe present the ten-year data of a cohort of patients, aged between 18 and 65 years (mean age 52.7 years; 19 to 64), who underwent total hip arthroplasty. Patients were randomised to be treated with a cobalt-chrome (CoCr) femoral head with an ultra-high molecular weight polyethylene (UHMWPE), highly cross-linked polyethylene (XLPE) or ceramic-on-ceramic (CoC) bearing surface.Patients and MethodsA total of 102 hips (91 patients) were randomised into the three groups. At ten years, 97 hips were available for radiological and functional follow-up. Two hips (two patients) had been revised (one with deep infection and one for periprosthetic fracture) and three were lost to follow-up. Radiological analysis was performed using a validated digital assessment programme to give linear, directional and volumetric wear of the two polyethylene groups.ResultsThere was a significantly reduced rate of steady-state linear wear with XLPE (0.07 mm/yr) compared with UHMWPE (0.37 mm/yr) (p = 0.001). Volumetric wear was also significantly reduced in the XLPE group (29.29 mm3/yr) compared with the UHMWPE group (100.75mm3/yr) (p = 0.0001). There were six patients with UHMWPE who had non-progressive osteolysis and none in the XLPE group. All three bearing groups had significant improvements in 12-item short form health survey scores, Western Ontario and McMaster Universities Osteoarthritis Index score and Harris Hip Score. However, the improvement in HSS was significantly less in the UHMWPE group (p = 0.0188) than in the other two groups. At ten years, the rates of volumetric and linear wear in the XLPE group remain low and predominantly below the estimated threshold for osteolysis (1 mm/yr). The rate of linear wear in the XLPE group was three times less than in the UHMWPE group at five-year follow-up and five times less at ten years. The rate of volumetric wear was also three times less in the XLPE group at ten years.ConclusionWhile CoC also performs well, XLPE at ten years remains a safe and excellent bearing option in young patients, with low rates of wear and no evidence of osteolysis. Cite this article: Bone Joint J 2017;99-B:1590–5.

ObjectiveTo evaluate the management and costs of osteoarthritis of the knee (OAK), a progressive joint disease due to bone and cartilage degeneration, with significant personal and societal impact.MethodsWe prospectively analyzed the clinical outcomes and quantifiable cumulative direct costs of patients with OAK referred to our multidisciplinary OA program over a two year time period. One hundred thirty-one subjects were assessed. All demonstrated radiographic criteria for moderate to severe OAK. Western Ontario McMaster Osteoarthritis Index (WOMAC), Minimal Clinically Important Improvement (MCII), and change in BMI were recorded and analyzed. Total medical and surgical direct costs for all subjects during the two year time period were determined.ResultsFive patients underwent total joint replacement during the two years of study. Among the group as a whole, a significant overall improvement in WOMAC scores was noted at the two year time point follow-up. After dividing the group into tertiles by baseline WOMAC scores, 46% achieved MCII. Significant weight loss was noted for individuals with baseline BMI of > 30. As all patients were considered “de facto” surgical candidates at referral, an average net savings of $9551.10 of direct costs per patient, or a potential total of $1,203,438.60 for the entire group, could be inferred as a result of medical as opposed to surgical management.ConclusionThese findings support the benefits of multidisciplinary medical management for patients with significant OAK. This approach is clinically beneficial and may provide significant cost savings. Such models of care can substantially improve the long-term outcome of this highly prevalent condition and reduce societal and financial burdens.

In 2009, the Ontario Ministry of Health and Long-Term Care engaged Cancer Care Ontario to expand the Wait Time Information System to capture surgical consultation data (Wait 1). Over the years, an increasing number of patient and provider reports have shown that Wait 1 wait times account for a significant portion of the total wait time for surgery. With data published online by the ministry in late summer 2017, patients were given access to consultation wait time information for over 200 types of procedures at 92 surgical facilities in Ontario. This article explains how a highly focused data strategy, strong stakeholder and clinical expert support and a comprehensive communications strategy were critical to driving change for a large-scale provincial initiative, which is helping to drive better access for patients and improve transparency and accountability.

© 2018 AABB BACKGROUND: Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS: A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury). Outcomes were compared in pre- and post-protocol groups with χ 2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS: No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS: Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.

Background There is no consensus regarding the effect of the type of deformities (valgus or varus) on the functional outcome of total knee arthroplasty (TKA). We aimed to compare the TKA outcome in varus and valgus patients to find whether different angulations of the knee could affect the functional outcome of the TKA. Methods In total, 55 valgus and 53 varus osteoarthritic knees with matched age, gender, BMI, tibiofemoral angle, comorbidities, type of prosthesis, and follow-up duration were included in the study. The mean follow-up of patients was 4.5 ± 1.7 years. The knee society score (KSS) was calculated for each knee at the latest follow-up. In addition, the western Ontario and McMaster Universities arthritis index (WOMAC) was assessed for each patient several times during the study in order to monitor the course of treatment. Results The total KSS was significantly higher in varus knees than in valgus knees, with the values of 82.80 ± 10.16 versus 78.61 ± 10.7, respectively (P = 0.023). Varus patients had a significantly better preoperative WOMAC index than valgus patients (with a score of 51.2 ± 4.05 vs. 42.21 ± 4.12) (P = 0.012). At the final follow-up, varus patients still had superior WOMAC although this difference was not statistically significant (P = 0.722). Interestingly, the WOMAC change in the first and final evaluations was significantly different in the two study groups, with 22.06 in varus and 30.14 in valgus patients (P < 0.001). Conclusions According to our results, the type of deformity could affect the long-term TKA outcome. In this regard, valgus patients would benefit more than varus patients from this surgery.

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.In Canada, hospitals admit 30 000 older adults with hip fracture annually.1 These patients face an increased risk of death, with up to 5% of women and 10% of men dying within 30 days.2,3 It is generally accepted that early operative intervention improves survival by reducing patients’ exposure to immobilization and inflammation.4 In 2005, the federal, provincial and territorial governments established a benchmark of 48 hours from admission for 90% of hip fracture surgeries to prevent potentially harmful delays.5 However, delays to hip fracture surgery remain common.6 Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.7,8There has been considerable debate about the point at which delaying hip fracture surgery for nonmedical reasons worsens mortality.9–25 This uncertainty leads to prioritization without benefit to the patient or underuse of expeditious surgery that could prevent deaths. Some have argued that understanding the effects of policy change should guide reorganization of operating room resources26 and prioritization in the presence of competing demand.7,27–29 In this paper, we offer 2 new estimates: the effect of possible changes in surgical timing policy in the same population of patients, and the proportion of in-hospital deaths attributable to surgical delays.

Background It has been suggested that total knee replacement is being performed in people with less-severe osteoarthritis. We aimed to determine whether there were differences in the presurgery profile, symptoms and disability of 2 cohorts who underwent total knee replacement over a 10-year period. Methods Patients aged 18-85 years undergoing primary total knee replacement for osteoarthritis at 1 of 4 sites in Toronto and Strathroy, Ontario, were recruited in a cohort study during 2006-2008 (cohort 1) and 2012-2015 (cohort 2). Patients undergoing unicompartmental or revision arthroplasty were excluded. Demographic and health (body mass index [BMI], comorbidity) variables and osteoarthritis severity, as assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the disability component of the Late-Life Function and Disability Instrument (LLFDI-D), were collected before surgery. We calculated proportions, means and standard deviations with 95% confidence intervals (CIs) for all data. We constructed density plots by tertile score for the WOMAC pain and physical function subscales and the LLFDI-D limitation scale. Results There were 494 patients in cohort 1 and 251 patients in cohort 2. There were no differences in age, sex, education, living status, BMI, comorbidity, pain severity or disability between the cohorts based on overlapping 95% CIs and the density plots. More patients in cohort 1 than in cohort 2 were single (176 [35.6%], 95% CI 32.5%-41.1% v. 63 [25.1%], 95% CI 20.3%-31.0%). Patients in cohort 2 reported less limitation in higher-demand activities than did those in cohort 1 (mean score on LLFDI-D 62.3 [95% CI 60.7-63.9] v. 59.2 [95% CI 58.2-60.2]). Interpretation The patient profile and reported osteoarthritis severity were similar in 2 cohorts that had total knee replacement over a 10-year period. This suggests that increasing total knee replacement volumes over this period likely were not driven by these factors.

Background The optimum bearing surface for total hip arthroplasty remains debatable. We have previously published our outcome at 10 years and this represents the 15-year follow-up. Methods A total of 58 hips (in 57 patients with a mean age of 42 years) were randomized to receive either ceramic-on-ceramic (CoC) or ceramic-on-polyethylene (CoP) total hip arthroplasty. We prospectively followed for survivorship, functional outcomes (using the Harris Hip Score and the St Michael’s Hip Score [SMH]), and radiological outcomes. Results At a minimum of 15 years, 3 patients had died, but not been revised. Seven were lost to follow-up. Five cases from the CoP group were revised (4 for polyethylene wear and osteolysis). Four from the CoC were revised; one each for head fracture, instability, infection, and trunnionosis. Both groups showed statistically significant improvements in Harris Hip Score scores and SMH functional scores, with no difference between the 2 bearings. For the CoP group, there was an improvement from 15.6 to 21.5 in the SMH and from 48.8 to 88.7 (P > .05); and for CoC, this improvement was 15.8 to 23.5 and 50.3 to 94.6 (P > .05), respectively. Mean wear rate of the polyethylene was 0.092 mm/y and for the CoC was 0.018 mm/y. Two patients in the CoC group had evidence of acetabular osteolysis vs 3 in the CoP. Six patients had femoral osteolysis in the CoC group and 12 in the CoP group. Conclusion Survivorship and function of the 2 bearing groups remains comparable; while the polyethylene wear and osteolysis may represent issues in the future.

The purpose of this review article was to investigate the incidence and predisposing factors for periprosthetic proximal femoral fractures (PFF) following total hip arthroplasty.We performed a comprehensive search of the medical literature in MEDLINE and EMBASE databases to review articles related to PFF, their incidence and risk factors.The incidence of PPF after primary THA was, in general, lower than after revision THA both for intra- and postoperative PFF. The rate of intraoperative PFF ranged from 0.1% to 27.8% and of postoperative PFF from 0.07% to 18%. Predisposing factors for intraoperative PFF are osteoporosis, rheumatoid arthritis, femoral preparation and surgical technique used to insert the rasp or femoral component, the use of press-fit cementless stems, and revision THA. In case of postoperative PFF, the following seem to be significant risk factors: advanced age, female gender, post-traumatic osteoarthritis, osteoporosis and rheumatoid arthritis, proximal femoral deformities, previous surgery of the affected hip, implant type (especially cementless stems and press-fit implantation), technical errors such as cortical perforation, cortical stress risers, low-energy trauma, osteolysis, loosening and revision THA.

As outlined in our January 16, 2013, editorial , “The Case Report Redefined with JBJS Case Connector ,” one important role of JBJS Case Connector is to alert the orthopaedic community about a potentially problematic device or therapy. When two or more such cases with similar mechanisms appear, we will identify the procedure or implant as a “watchable” intervention. While this system is not statistically conclusive and may or may not be supported by other published case reports or registry data, the intention is to sharpen the focus of clinicians on the potential for similar problems and thereby enhance clinical outcomes and patient safety. The “Watch” designation may also encourage others to report related difficulties and enlist the orthopaedic community to either demonstrate that these are isolated, unrelated cases or sharpen the focus further on rigorously evaluating the intervention. Where appropriate, we may identify brand, model, or implant-lot specifics. In total hip arthroplasty (THA), a fractured ceramic head is a catastrophic but thankfully very rare event. Most case reports of ceramic head fractures involve ceramic-on-ceramic articulations, but this “Watch” describes three cases of femoral head fractures involving ceramic-on-polyethylene bearings. Moreover, the fractures occurred in association with little or no postsurgical trauma. Ceramic hip components are often chosen for younger patients in an effort to minimize long-term wear. On the downside, unlike metal, ceramic components can fracture. Ceramic femoral head fractures arise from four main factors: trauma; material or manufacturing defects; non-compatible, damaged, or contaminated femoral stem/head taper connections; or other suboptimal surgical techniques. The ceramics industry has a more-than-forty-year track record of continuous improvement in hip-component manufacturing. CeramTec, the main U.S. player in this arena, first introduced ceramic hip components in 1974; those first-generation femoral heads had a fracture rate of 0.026%. By 2003, when CeramTec introduced its fourth-generation BIOLOX …

PurposeFailure to account for medically necessary delays may lead to an underestimation of early surgery benefits. This study investigated the feasibility of using administrative data to identify the National Institute for Health and Care Excellence (NICE) 124 guideline list of conditions that appropriately delay hip fracture surgery.MethodsWe assembled a list of diagnosis and procedure codes to reflect the NICE 124 conditions. The list was reviewed and updated by an advanced clinical coder. The list was refined by five clinical experts. We then screened Canadian Institute for Health Information discharge abstracts for 153 918 patients surgically treated for a non-pathological first hip fracture between 1 January 2004 and 31 December 2012 for diagnosis codes present on admission and procedure codes that antedated hip fracture surgery. We classified abstracts as having medical reasons for delaying surgery based on the presence of these codes.ResultsIn total, 10 237 (6.7%; 95% CI 6.5% to 6.8%) patients had diagnostic and procedure codes indicating medical reasons for delay. The most common reasons for medical delay were exacerbation of a chronic chest condition (35.9%) and acute chest infection (23.2%). The proportion of patients with reasons for medical delays increased with time from admission to surgery: 3.9% (95% CI 3.6% to 4.1%) for same day surgery; 4.7% (95% CI 4.5% to 4.8%) for surgery 1 day after admission; 7.1% (95% CI 6.9% to 7.4%) for surgery 2 days after admission; and 15.5% (95% CI 15.1% to 16.0%) for surgery more than 2 days after admission. The trend was seen for admissions on weekday working hours, weekday after hours and on weekends.ConclusionAdministrative data can be considered to identify conditions that appropriately delay hip fracture surgery. Accounting for medically necessary delays can improve estimates of the effectiveness of early surgery.

© 2017 Elsevier Ltd Introduction: The incidence of periprosthetic femoral fractures around total hip arthroplasties is increasing. Fractures around a stable implant stem (Vancouver type B1) are among the most common of these fractures. Various fixation strategies for Vancouver type B1 periprosthetic fractures have been reported in the literature; however, little high-level evidence exists. This study was designed to determine the current management strategies and opinions among orthopaedic surgeons treating Vancouver type B1 periprosthetic femoral fractures, and to evaluate the need for a large prospective randomized controlled trial for the management of these injuries. Methods: Orthopaedic surgeon members of the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the Hip Society were invited to participate in a 51-item web-based survey surrounding the management of periprosthetic femoral fractures around total hip replacements, as well as the perceived need for future research in this area. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training. Results: For Vancouver type B1 fractures, open reduction and internal fixation (ORIF) with locked plating was favoured slightly over ORIF with cable plating ± cortical strut allograft (51.1% versus 45.5%). When compared to cable plating with cortical strut allograft, respondents believed that isolated locked plating resulted in lower nonunion and reoperation rates, but similar infection and malunion rates. Subgroup analyses revealed that practice type, surgeon age, case volume, and fellowship training influenced surgeons’ management of periprosthetic femoral fractures and beliefs regarding complications. There is high demand for a large prospective randomized controlled trial for Vancouver type B1 fracture fixation. Conclusions: Consensus surrounding the management of Vancouver type B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries.

As the number of primary total hip arthroplasties increases, so does the burden of revision procedures. The decision to revise well-fixed components in the setting of polyethylene wear and osteolysis is controversial. Modular head and liner exchange offers the advantages of reduced invasiveness, faster recovery, and bone preservation. These advantages come at the expense of higher rates of revision surgery for instability. Using the native locking mechanism for securing the new liner is preferred; however, cementing a liner into a well-fixed acetabular component is a practical alternative. The use of bone allograft or bone graft substitute for areas of osteolysis is controversial. In the setting of osteolysis, outcomes associated with the use of highly cross-linked polyethylene liners have been better than those associated with the use of conventional polyethylene; therefore, thinner liners and larger femoral heads can be used and reduce the risk of instability.

Background The ideal bearing combination for total hip arthroplasty (THA) remains debatable. Highly cross-linked polyethylene (XLPE) is widely used, but long-term wear rates are not fully known, nor is how much the initial "creep," if any, affects overall wear. Additionally, the use of oxidized zirconium (OxZir) is purported to lower polyethylene wear rates, but this has not been proven. We present the 10-year data of a cohort of patients who underwent THA. Patients were prospectively randomized to 1 of 4 bearing combinations: a conventional ultra-high molecular weight polyethylene (UHMWPE) or XLPE acetabular liner coupled with either a cobalt-chromium (CoCr) or OxZir femoral head. The aims of the study were to (1) assess the extent to which creep affected overall wear rates and (2) assess wear rates between OxZir and CoCr with polyethylene. Methods A total of 92 hips (92 patients) between the ages of 22 and 65 years (mean, 52.2 ± 9.3 years) were randomized to 4 groups. At 10 years, 70 (76%) of the hips were available for analysis; patients who had undergone revision, had died, or were lost to follow-up were excluded from final analysis. Radiographic analysis was performed using a validated digital assessment program to determine linear, volumetric, and directional wear of the polyethylene for all 4 bearing couples. Radiographic assessments were performed immediately postoperatively, at 6 and 12 weeks, and then annually for a minimum of 10 years. Results XLPE had significantly lower wear rates than UHMWPE. Once creep was eliminated, annual and overall wear rates were nearly 50% lower than have been previously reported. This was proportionally more important in the XLPE group than in the UHMWPE group. There was a nonsignificant trend toward a lower wear rate with OxZir heads. Conclusions Creep plays a notably more important role than first thought. Once creep was eliminated, the overall wear rate was even lower than previously assumed. This has important implications for the overall survivorship of hip arthroplasty implants. Level of Evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

© 2015, The Association of Bone and Joint Surgeons®. Background: Despite modern fracture management techniques allowing for near anatomic reduction of acetabular fractures, there continues to be a risk of posttraumatic arthritis and need for total hip arthroplasty (THA). Few well-controlled studies have compared THA after acetabular fractures with THAs performed for other indications in terms of survivorship or complications, and none, to our knowledge, present 10-year survivorship data in this setting. Questions/purposes: (1) How does the 10-year survival of THA compare between those patients who underwent THA after an acetabular fracture and those who underwent THA for primary arthritis or avascular necrosis (AVN)? (2) Is there an increased risk of serious complications like infection, dislocation, and aseptic loosening as well as heterotopic ossification associated with a THA performed after a previous acetabular fracture? Methods: This retrospective case-control study compared findings of patients who underwent THA after acetabular fracture versus a matched cohort of patients who had received a primary THA for primary osteoarthritis or AVN. Between 1987 and 2011, we performed 95 THAs after acetabular fracture; of those, 74 (78%) met inclusion criteria and had documented followup beyond 2 years in our institutional registry. We selected 74 matched patients based on an algorithm that matched patients based on preoperative diagnosis, date of operation, age, gender, and type of prosthesis. During this time, we performed approximately 8000 THAs that were potentially available for matching based on complete followup beyond 2 years. We compared cases and control subjects using the Kaplan-Meier survivorship estimator as well as a comparison of the proportions in each group that developed major complications (including infection, dislocation, loosening, and heterotopic ossification) based a retrospective chart review. Results: The 10-year survivorship after THA was lower in patients with a previous acetabular fracture than in the matched cohort (70%, 95% confidence interval [CI], 64%–78%, versus 90%, 95% CI, 86–95%; p < 0.001). There was no difference in the 10-year survival rate for those patients whose acetabular fracture was initially treated conservatively and those treated by open reduction and internal fixation. Patients with previous acetabular fracture had a higher likelihood of developing infection (7% [five of 74] versus 0% [zero of 74]; odds ratio [OR], 11.79; p = 0.028), dislocation (11% [eight of 74] versus 3% [two of 74]; OR, 4.36; p = 0.048), or heterotopic ossification (43% [32 of 74] versus 16% [12 of 74]; OR, 3.93; p < 0.001). Conclusions: In this case-control study, patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary osteoarthritis or AVN. Given these findings, management of these complex cases should be in highly specialized units where the expertise of arthroplasty and trauma reconstruction is available. Level of Evidence: Level III, therapeutic study.

In an effort to reduce wait times associated with joint replacement surgery, the overall arthroplasty caseload in the province in Ontario has increased by more than 50% in the past 5 years.1,2 As a result, the number of total joint arthroplasties being performed during a surgical day has also increased. Many surgeons now perform 5 or 6 total joint operations in a single day, with operative working hours approaching 10. There is no doubt that this increased caseload has led to increased surgeon fatigue, particularly for cases performed at the end of the operating day compared with those performed at the beginning. There is growing support in the literature that patient outcomes are adversely affected by fatigue in operator-dependent cognitive and technical tasks. Adverse events and medical errors have been shown to occur more frequently in sleep-deprived physicians, and technical skills have also been shown to be negatively influenced by physician fatigue.3–9 More specifically, laparoscopic procedures,10 cardiac interventions,11 endotracheal intubation12 and colonoscopies13,14 have been shown to have inferior outcomes when performed later in the day. These findings potentially have implications for physician productivity, procedural outcome and, most importantly, patient safety. There are many factors that contribute to the outcome of total joint arthroplasty, including preoperative, intraoperative and postoperative variables. It is well established that preoperative variables, such as unrealistic patient expectations,15–18 diabetic control19,20 and obesity,21–23 can have a negative effect on radiologic and functional outcomes. Fortunately, these variables are modifiable and therefore have the potential to be optimized preoperatively. Postoperative variables, such as participation in rehabilitation and avoidance of limb positions that may predispose to hip dislocation, are also modifiable variables that have been shown to affect outcome.24,25 The influence of intraoperative variables on outcomes in total joint arthroplasty have been less extensively studied. Duration of the surgical procedure,26,27 blood loss28 and component alignment29–33 are modifiable intraoperative variables that influence patient outcomes and may be adversely affected by surgeon fatigue. To our knowledge, the extent to which fatigue affects the technical and cognitive skills of the surgeon and overall patient outcomes in total joint arthroplasty has not previously been studied. The purpose of this retrospective study was to determine whether there is a difference, in terms of perioperative and postoperative complications, between patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) at different times during the operative day.

Sagittal alignment of tibial components using computer navigation was compared with conventional methods. A radiologic study was performed using 110 total knee arthroplasties from 3 groups: computer navigation, cutting block with extramedullary guide, and manual tilt of extramedullary guide. Posterior tibial slopes were measured from radiographs and compared using statistical methods. The cutting block method was the most accurate, and computer navigation was the most precise. The manual tilt group had the greatest variance, significantly greater than computer navigation. There was no significant difference between groups with respect to the percentage of knees with posterior slope within 3° of the desired slope. Meta-analysis of 10 studies found no reduction in outliers with computer navigation. Computer navigation offers greatest precision but does not reduce the number of outliers.

Background: The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with abnormal femoral head anatomy. Methods: The current study examines whether a bone-preserving femoral component that is fixed into the femoral neck metaphysis provides a mechanical advantage in terms of resisting femoral neck fracture in comparison with a conventional hip resurfacing implant in a human cadaveric femoral model. Results: Femora with a BMHR femoral component failed at an average of 23% less load than those prepared with a conventional hip resurfacing component (mean and standard deviation, 5434 ± 2297 compared with 7012 ± 2619 N; p < 0.001). Conclusions: An uncemented, metaphyseal fixed, bone-conserving femoral implant does not provide superior mechanical strength or increased resistance to femoral neck fracture in comparison with a conventional hip resurfacing arthroplasty.

Background: The aim of this study was to assess the outcome of immediate plate osteosynthesis in the surgical treatment of open humeral shaft fractures. Methods: In a Level I trauma center and teaching hospital, we reviewed 53 patients with open humeral diaphyseal fractures who were treated with immediate open reduction and plate fixation from April 1988 to August 1998. Forty-six patients were available for adequate follow-up and assessment. All fractures were treated with a standard protocol that included irrigation and debridement, intravenous antibiotics, and immediate open reduction and plate fixation. Patients were assessed to determine whether bone grafts were needed during surgery, whether bone union was achieved, the state of the radial nerve, and postoperative complications. No quantitative functional outcomes were assessed, because this was beyond the scope of the study. It was hypothesized that immediate plate osteosynthesis would achieve safe and acceptable clinical results. Results: The 46 patients with adequate final follow-up were assessed at a mean time of 37.5 weeks (13-156 weeks). All fractures united primarily in satisfactory angulation

The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with compromised femoral head anatomy. The current study examined the effect of coronal implant alignment and femoral neck notching on proximal femoral strength with the BMHR. Neither relative valgus nor varus implant alignment had a significant impact on femoral strength compared to neutrally aligned, matched, paired cadaveric specimens. A 5-mm superior neck notch significantly weakened BMHR-implanted synthetic femurs compared to unnotched controls, whereas a 2-mm notch did not significantly affect ultimate failure load. Relative valgus alignment had a protective effect on a full-cortical-thickness superior neck notch. Mid-head resection arthroplasty may be more forgiving to minor preparatory errors than a typical hip resurfacing.

Nonunion of fractures about the femoral neck and intertrochanteric hip regions is uncommon. Patients who develop nonunions of these fractures typically exhibit marked pain and disability, thereby presenting a treatment challenge to the orthopaedic surgeon. Factors that guide the choice of salvage treatment include the anatomic site of the nonunion, the quality of the remaining proximal bone and articular surface, and patient factors (such as age and activity level). In the younger patients with a well-preserved hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. However, in older patients, it is more common to encounter poor remaining proximal bone stock or a badly damaged hip joint from hardware cutout. As such, conversion to hip arthroplasty is intended to help effectively restore function and relieve pain. With respect to salvage procedures for the femoral head, the major challenges in decision making include the choice of both internal fixation device and accurate preoperative planning. The challenges involved in planning to convert to hip arthroplasty include the need for acetabular resurfacing, selecting the femoral implant, and managing discontinuity of the greater trochanter. Furthermore, there are additional technical challenges that may be encountered, such as broken hardware, deformity, and femoral bone defects. Overall, salvage of nonunions of femoral neck and intertrochanteric hip fractures in properly selected patients can provide patients with good to excellent results.

Closing wedge high tibial osteotomy is a common, effective and well-established procedure to treat unicompartment osteoarthrosis of the knee. It is, however, not without its complications. This article will discuss some of these complications and present an overview of the current literature. It will examine current thoughts on aetiology, techniques to try to avoid, and methods of treatment of these complications.

The Joint Health and Disease Management Program in the Toronto Central Local Health Integration Network (TC LHIN) is envisioned as a comprehensive model of care for patients with hip and knee arthritis. It includes access to assessment services, education, self-management programs and other treatment programs, including specialist care as needed. As the first phase of this program, the hospitals in TC LHIN implemented a Hip and Knee Replacement Program to focus on improving access and quality of care, coordinating services and measuring wait times for patients waiting for hip or knee replacement surgery. The program involves healthcare providers, consumers and constituent hospitals within TC LHIN. The approach used for this program involved a definition of governance structure, broad stakeholder engagement to design program elements and plans for implementation and communication to ensure sustainability. The program and approach were designed to provide a model that is transferrable in its elements or its entirety to other patient populations and programs. Success has been achieved in creating a single wait list, developing technology to support referral management and wait time reporting, contributing to significant reductions in waits for timely assessment and treatment, building human resource capacity and improving patient and referring physician satisfaction with coordination of care.

Background: A variety of methods are available for the fixation of femoral shaft fractures after total hip arthroplasty. However, few studies in the literature have quantified the performance of such repair constructs. The aim of this study was to evaluate biomechanically four different constructs for the fixation of periprosthetic femoral shaft fractures following total hip arthroplasty. Methods: Twenty synthetic femora were tested in axial compression, lateral bending, and torsion to determine initial stiffness, as well as stiffness following fixation of a simulated femoral midshaft fracture with and without a bone gap. Four fracture fixation constructs (five specimens per group) were assessed: construct A was a Synthes locked plate (a twelve-hole broad dynamic compression plate) with locked screws; construct B, a Synthes locked plate (a twelve-hole broad dynamic compression plate) with cables and locked screws; construct C, a Zimmer nonlocking (eight-hole) cable plate with cables and nonlocked screws; and construct D, a Zimmer nonlocking (eight-hole) cable plate with allograft strut, cables, and nonlocked screws. Axial stiffness, lateral bending stiffness, and torsional stiffness were assessed with respect to baseline intact specimen values. Axial load to failure was also measured for the specimens. Results: Construct D demonstrated either equivalent or superior stiffness in all testing modes compared with the other constructs in femora with both a midshaft fracture and a bone gap. A comparison of constructs A, B, and C demonstrated equivalent stiffness in all test modes (with one exception) in femora with a midshaft fracture and a bone gap. Conclusions: A combination of a nonlocking plate with an allograft strut (construct D) resulted in the highest stiffness of the constructs examined for treating a periprosthetic fracture around a stable femoral component of a total hip replacement. Clinical Relevance: A locked plate (constructs A and B) should be used with caution as a stand-alone treatment for the fixation of a periprosthetic femoral shaft fracture following total hip arthroplasty, particularly with good bone stock.

Nonunion is a relatively common complication of proximal femoral fracture resulting from poor mechanical alignment of the fracture, failure of internal fixation, poor biologic factors, or infection. In this article, we discuss surgical procedures for the salvage of both femoral neck fracture and intertrochanteric hip fracture nonunion. These procedures include proximal femoral valgus osteotomy for femoral neck fracture nonunion, revision open reduction with internal fixation for intertrochanteric hip fracture nonunion, and hip arthroplasty. Preoperative planning, surgical technique, common complications, and results from the literature for these procedures are discussed.