Aims Periprosthetic joint infection (PJI) remains a serious complication of arthroplasty, associated with increased morbidity, mortality, and healthcare costs. While patient-related and procedural risk factors are well established, the effect of surgical gown type on infection risk is unclear. Single-use surgical gowns are often used due to their perceived superior sterility in the absence of clear evidence. The purpose of this study was to determine the effect of single-use compared with reusable gown use on the incidence of PJI in the 12 months following primary hip and knee arthroplasty. Methods Between January 2015 and September 2023, 9,239 consecutive primary elective hip and knee arthroplasties were performed at our institution. Data were obtained from a prospectively maintained local registry aligned with the UK Health Security Agency Surgical Site Infection database and National Joint Registry, and combined with surgeon gown preference data. A retrospective logistic regression was undertaken to evaluate the association between gown type and PJI in the 12 months after surgery, adjusting for age, sex, BMI, diabetes, and chronic obstructive pulmonary disease (COPD). Results A total of 76 infections (0.82%) were identified, comprising 49/5,024 knees (0.98%) and 27/4,215 hips (0.64%). Infection occurred more frequently in the single-use gown group (n = 4,314; 1.0%) than in the reusable gown group (n = 4,925; 0.6%; p = 0.017). Single-use gowns were associated with higher odds of infection (adjusted odds ratio (OR) 1.73 (95% CI 1.09 to 2.76); p = 0.020). Conclusion Use of single-use surgical gowns was independently associated with an increased odds of PJI following primary hip and knee arthroplasty in the 12 months after surgery in our institution. This finding highlights the need for further studies exploring the causal factors contributing to this outcome.

Aims:Periprosthetic joint infection (PJI) remains a serious complication of arthroplasty, associated with increased morbidity, mortality, and healthcare costs. While patient-related and procedural risk factors are well established, the effect of surgical gown type on infection risk is unclear. Single-use surgical gowns are often used due to their perceived superior sterility in the absence of clear evidence. The purpose of this study was to determine the effect of single-use compared with reusable gown use on the incidence of PJI in the 12 months following primary hip and knee arthroplasty. Methods:Between January 2015 and September 2023, 9,239 consecutive primary elective hip and knee arthroplasties were performed at our institution. Data were obtained from a prospectively maintained local registry aligned with the UK Health Security Agency Surgical Site Infection database and National Joint Registry, and combined with surgeon gown preference data. A retrospective logistic regression was undertaken to evaluate the association between gown type and PJI in the 12 months after surgery, adjusting for age, sex, BMI, diabetes, and chronic obstructive pulmonary disease (COPD). Results:A total of 76 infections (0.82%) were identified, comprising 49/5,024 knees (0.98%) and 27/4,215 hips (0.64%). Infection occurred more frequently in the single-use gown group (n = 4,314; 1.0%) than in the reusable gown group (n = 4,925; 0.6%; p = 0.017). Single-use gowns were associated with higher odds of infection (adjusted odds ratio (OR) 1.73 (95% CI 1.09 to 2.76); p = 0.020). Conclusion:Use of single-use surgical gowns was independently associated with an increased odds of PJI following primary hip and knee arthroplasty in the 12 months after surgery in our institution. This finding highlights the need for further studies exploring the causal factors contributing to this outcome.

BACKGROUND:Cemented polished taper-slip (PTS) stems are widely used in total hip arthroplasty but are associated with an increased risk of periprosthetic femoral fracture. Stem centralizers enable surgeons to achieve an even cement mantle and allow for controlled subsidence, which is essential for maintaining fixation, as this relies on the PTS implant's interaction with the surrounding cement mantle (known as a "force-closed" mechanism). However, if subsidence exceeds the centralizer's limit, the implant transitions to a configuration where fixation depends on direct mechanical interlocking with the cement mantle (a "shape-closed" mechanism), potentially increasing stresses within the cement mantle. The aim of this study was to quantify the stress distribution changes within the cement mantle when further subsidence is restricted using finite element analysis (FEA). METHODS:Three commonly used PTS designs: C-Stem AMT (Johnson & Johnson MedTech, Warsaw, IN, USA), Exeter (Stryker, Kalamazoo, MI), and CPT (Zimmer Biomet, Warsaw, IN), were 3D scanned and modelled, incorporating cement mantle and centralizer gaps per manufacturer guidelines. FEA simulated loading conditions mimicking a stumble (6,900 N) with and without a distal gap to assess von Mises stress and deformation. Variations in stem materials (Stainless steel (SS316L) and Co-Cr alloys) and friction coefficient were also evaluated. RESULTS:With subsidence allowance, peak von Mises stresses were concentrated in the medial calcar (Gruen zone 7), with CPT stems showing the highest stress (~45 MPa). When subsidence was restricted, stress shifted to the distal tip (zone 4), increasing by 49-102% depending on stem design and material. Co-Cr stems exhibited higher stress and displacement at the distal tip compared to SS316L stems. CONCLUSIONS:Restricting subsidence in PTS stems significantly increases distal cement mantle stress, which may elevate PPF risk. Stem design, material and implant-cement interface friction influence stress distribution and subsidence behavior, potentially affecting long-term implant stability.

Aims:In this study, we report the impact of implementing a new short-stay hip and knee arthroplasty pathway in an NHS hospital. This was enacted due to existing concerns around long length of stay (LOS) and reduced elective operating capacity each winter due to bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimize readmission rates, and generate financial savings, all combining to facilitate full elective activity during the winter. Methods:We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It included rigorous preoperative optimization, specific anaesthetic protocols, and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, encompassing the initial six months post-implementation of the short-stay pathway. LOS data were collected for the full period and data were compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. Results:There was a significant decrease in median LOS from four days pre-implementation to one day post-implementation. Patient satisfaction was high and the 30-day readmission rate was unchanged (5.95%, n = 43), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine postoperative blood tests. Elective activity over winter was significantly higher (203 more arthroplasties, 79% increase) than in the same time period in the previous year. Conclusion:An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective, and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS.

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long- term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

BACKGROUND:Trabecular metal is being increasingly used in primary total hip arthroplasty (THA). This study compared medium-term (< 15 years) outcomes of fiber mesh titanium and trabecular metal acetabular components. METHODS:This study included 6,563 patients who underwent primary THA with either fiber mesh titanium or trabecular metal-backed acetabular components. Data were sourced from a prospectively maintained local arthroplasty database and linked with the National Joint Registry. RESULTS:The 10-year survivorship was 97.3% for fiber mesh and 98.9% for porous tantalum groups (P = 0.009). Multivariate analysis showed no significant variable associated with reduced revision rates. CONCLUSIONS:Both fiber mesh titanium and trabecular metal acetabular components demonstrated high survivorship in THA, with trabecular metal showing statistically significant though marginally better survival. Despite the increased cost associated with trabecular metal, its use may be justified in complex primary and revision cases where increased primary stability may be required. Future research should focus on cost analysis and include patient-reported outcomes to guide implant selection further.

AbstractObjectivesTotal hip replacement (THR) is one of the most successful and cost-effective interventions in orthopaedic surgery. Dislocation is a debilitating complication of THR and managing an unstable THR constitutes a significant clinical challenge. Stability in THR is multifactorial and is influenced by surgical, patient and implant related factors. It is established that larger diameter femoral heads have a wider impingement-free range of movement and an increase in jump distance, both of which are relevant in reducing the risk of dislocation. However, they can generate higher frictional torque which has led to concerns related to increased wear and loosening. Furthermore, the potential for taper corrosion or trunnionosis is also a potential concern with larger femoral heads, particularly those made from cobalt-chrome. These concerns have meant there is hesitancy among surgeons to use larger sized heads. This study presents the comparison of clinical outcomes for different head sizes (28mm, 32mm and 36mm) in primary THR for 10,104 hips in a single centre.MethodsA retrospective study of all consecutive patients who underwent primary THR at our institution between 1st April 2003 and 31st Dec 2019 was undertaken. Institutional approval for this study was obtained. Demographic and surgical data were collected. The primary outcome measures were all-cause revision, revision for dislocation, and all-cause revision excluding dislocation. Continuous descriptive statistics used means, median values, ranges, and 95% confidence intervals where appropriate. Kaplan-Meier survival curves were used to estimate time to revision. Cox proportional hazard regression analysis was used to compare revision rates between the femoral head size groups. Adjustments were made for age at surgery, gender, primary diagnosis, ASA score, articulation type, and fixation method.Results10,104 primary THRs were included; median age 68.6 years with 61.5% females. A posterior approach was performed in 71.6%. There were 3,295 hips with 28 mm heads (32.6%), 4,858 (48.1%) with 32 mm heads and 1,951 (19.3%) with 36 mm heads. Overall rate of revision was 1.7% with the lowest rate recorded for the 36mm group (2.7% vs. 1.3% vs. 1.1%). Cox regression analysis showed a decreased risk of all-cause revision for 32mm & 36mm head sizes as compared to 28mm; this was statistically significant for the 32mm group (p = 0.01). Risk of revision for dislocation was significantly reduced in both 32mm (p = 0.03) and 36mm (p = 0.03) head sizes. Analysis of all cause revision excluding dislocation showed no significant differences between head sizes.ConclusionThere was a significantly reduced risk of revision for all causes, but particularly revision for dislocation with larger head sizes (36mm & 32mm vs. 28mm). Concerns regarding increased risk of early revision for aseptic loosening, polyethylene wear or taper corrosion with larger heads appear to be unfounded in this cohort of 10,104 patients with a mean of 6.0-year follow-up.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Orthopaedic hip implants have seen significant advances over the years; however, their long-term success depends on multiple factors, such as correct implantation, host acceptability, wear characteristics and, most importantly, fixation between the host bone and implant. The most common reason for revision surgery, aseptic loosening, carries a heavy morbidity and financial cost burden for the patient and health services. Whilst much time has been invested in understanding and optimising implant fixation to the host bone, the importance of early diagnosis of failed osseointegration cannot be understated. This chapter explores the biology behind osseointegration, osteolysis, and the advances made towards enhanced fixation. Signs and symptoms suggesting failed osseointegration and the diagnostic tests currently used to identify aseptic loosening and osteolysis are described. Furthermore, we explore the utility of molecular biomarkers that have the potential to aid early diagnosis and thus prevent catastrophic complications and the need for complex revision surgery.

Sound management decisions are critical to outcomes in revision arthroplasty. Aiming to improve outcomes, revision networks facilitate speciality trained, high volume surgeons, share experience and best practice, contributing to decision making within and away from their base hospital. We have reported the early clinical experience of East Midlands Specialist Orthopaedic Network (EMSON). In this paper we report beneficial clinical effects, both demonstrable and unquantifiable supporting the process. Using the UK HES database of revisions, performed before and after EMSON was established, (April 2011 – March 2018), data from EMSON hospitals were compared to all other hospitals in the same time-period. Primary outcome was re-revision surgery within 1 year. Secondary outcomes were re-revision, complications within first two years and median LOS. 57,621 RTHA and 33,828 RTKA procedures were involved with around 1,485 (2.6%) and 1,028 (3.0%) respectively performed within EMSON. Re-revision THA rates, within 1 year, in EMSON were 7.3% and 6.0% with re-revision knee rates 11.6% and 7.4%, pre- and post-intervention. Re-revision rates in the rest England in the same periods were 7.4% to 6.8% for hips and 11.7% to 9.7% for knees. This constituted a significant improvement in 1-year re-revision rates for EMSON knees. (β = −0.072 (−0.133 to −0.01), p = 0.024). The reduction in hip re-revision did not reach statistical significance. Secondary outcomes showed a significant improvement for 1 and 2-year RTHA complication rates. Re-revision rates for RTKA and complication rates for RTHA improved significantly after the introduction of EMSON. Other outcomes studied also improved to a greater extent in the network hospitals. While anecdotal experience with networks is positive, the challenge in collating data to prove clinic benefit should not be underestimated. Beyond the formal process, additional communication, interaction, and support has immeasurable benefit in both elective and emergency scenarios.

BACKGROUND:We aimed to compare the clinical outcomes of different head sizes (28-, 32-, and 36- millimeter) in primary total hip arthroplasty (THA) at mean 6 years follow-up (range, 1 to 17.5 years). METHODS:This was a retrospective consecutive study of primary THA at our institution (2003 to 2019). Demographic and surgical data were collected. The primary outcome measures were all-cause revision, revision for dislocation, and all-cause revision excluding dislocation. Continuous descriptive statistics used means, median values, ranges, and 95% confidence intervals, where appropriate. Kaplan-Meier survival curves were used to estimate time to revision. Cox proportional hazard regression analyses were used to compare revision rates between the femoral head size groups. Adjustments were made for age at surgery, sex, primary diagnosis, American Society of Anesthesiologists score, articulation type, and fixation methods. There were 10,104 primary THAs included; median age was 69 years (range, 13 to 101) with 61.5% women. A posterior approach was performed in 71.6%. There were 3,295 hips with 28-mm heads (32.6%), 4,858 (48.1%) with 32-mm heads, and 1,951 (19.3%) with 36-mm heads. RESULTS:Overall rate of revision was 1.7% with the lowest rate recorded for the 36-mm group (2.7 versus 1.3 versus 1.1%). Cox regression analyses showed a decreased risk of all-cause revision for 32 and 36-mm head sizes as compared to 28-mm; this was statistically significant for the 32-mm group (P = .01). Risk of revision for dislocation was significantly reduced in both 32-mm (P = .03) and 36-mm (P = .03) head sizes. Analysis of all cause revision excluding dislocation showed no significant differences between head sizes. CONCLUSIONS:We found a significantly reduced risk of revision for all causes, but particularly revision for dislocation with larger head sizes. Concerns regarding increased risk of early revision for aseptic loosening, polyethylene wear, or taper corrosion with larger heads appear to be unfounded in this cohort of 10,104 patients with up to 17 years follow-up.

BACKGROUND:The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA).METHODS:A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge.RESULTS:Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days.CONCLUSION:There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges.Cite this article: Bone Joint J 2020;102-B(6):661–663.

Excellent exposure is an essential requirement for successful hip surgery. The surgical approach selected should provide appropriate exposure of the acetabulum together with safe mobilization and exposure of the proximal femur. The approach should be versatile, allowing adequate release and exposure in the various circumstances in which primary hip arthroplasty is indicated. It should be extensile, allowing intraoperative flexibility, safe, avoiding significant risk to adjacent neurovascular structures and limit soft tissue damage and blood loss. This review article describes the common surgical approaches used for primary total hip replacement, reviewing those in common use and discussing reduced access variations on those approaches. Newer trends, such as the direct anterior approach and the direct superior approaches will be described. The strengths, limitations and clinical evidence related to each option will be discussed.

Patients having to apply for exceptional funding when referred for hip surgery, which is increasingly refused, is concerning.1 Although many patients with hip arthritis are successfully managed conservatively, symptoms worsen with compromised function and increasing pain. Prolonged waiting times lead to worsening deformity, muscle wasting, and bone loss, which compromise outcomes and increase complications. Timing of referral is critical. Anecdotally, surgeons …

AbstractIntroductionRevision total knee arthroplasty (RTKA) is a complex procedure with higher rates of re-revision, complications and mortality compared to primary TKA. We report the effects of the establishment of a Revision Arthroplasty Network (The East Midlands Specialist Orthopaedic Network; EMSON).MethodologyThe Revision Arthroplasty Network was established in January 2015 and covered the Nottinghamshire and Lincolnshire areas of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming RTKA procedures are discussed, and a plan agreed.Using the Hospital Episode Statistics database, RTKA procedures carried out between 2011 and 2018 from the five EMSON hospitals were compared to all other hospitals in England. Age, sex, and Hospital Frailty Risk scores were used as covariates.The primary outcome was re-revision surgery within 1 year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years and median length of stay.Results33,828 RTKA procedures were performed across England; 1,028 (3.0%) were conducted within EMSON. Re-revision rates within 1 year were 11.6% and 7.4% pre- and post-intervention respectively within the network. This compares to a pre-post change from 11.7% to 9.7% for the rest of England. In comparative interrupted time-series analysis, there was a significant immediate improvement in re-revision rates for EMSON hospitals compared to the rest of England at 1 year (p = 0.024) and 2 years (p=0.032).ConclusionRe-revision rates for RTKA improved significantly at one and two years with the introduction of EMSON, when compared to the rest of England.

Acetabular reconstruction can be a major challenge in revision hip surgery. A wide variety of potential defects confronts the surgeon, from an essentially intact acetabulum to the complex, but thankfully rare, discontinuity. This review will demonstrate that careful review of pre-operative imaging with defect classification allows the surgeon to ‘characterise’ potential bone loss and identify what he/she is likely to encounter, helping the surgeon to plan and to effect a sound reconstruction. We aim to describe some of the techniques that can assist the surgeon and to demonstrate how recent advances in materials, with porous metal components, have shown encouraging results in even the most severe defects.