Controversies around hip fracture treatment: clinical evidence versus trends from national registries.

PURPOSE: Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice. METHODS: A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand). RESULTS: For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries. CONCLUSIONS: Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.

Consultant revision hip arthroplasty volumes and new consultant volume trajectories in England, Wales, Northern Ireland, and the Isle of Man.

Aims: This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice. Methods: National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man were received for 84,816 RHAs and 818,979 PHAs recorded between April 2011 and December 2019. RHA data comprised all revision procedures, including first-time revisions of PHA and any subsequent re-revisions recorded in public and private healthcare organizations. Annual procedure volumes undertaken by the responsible consultant surgeon in the 12 months prior to every index procedure were determined. We identified a cohort of 'new' HA consultants who commenced practice from 2012 and describe their rate of accrual of PHA and RHA experience. Results: The median annual consultant RHA volume, averaged across all cases, was 21 (interquartile range (IQR) 11 to 34; range 0 to 181). Of 1,695 consultants submitting RHA cases within the study period, the top 20% of surgeons by annual volume performed 74.2% of total RHA case volume. More than half of all consultants who had ever undertaken a RHA maintained an annual volume of just one or fewer RHA, however, collectively contributed less than 3% of the total RHA case volume. Consultant PHA and RHA volumes were positively correlated. Lower-volume surgeons were more likely to undertake RHA for urgent indications (such as infection) as a proportion of their practice, and to do so on weekends and public holidays. Conclusion: The majority of RHAs were undertaken by higher-volume surgeons. There was considerable variation in RHA volumes by indication, day of the week, and between consultants nationally. The rate of accrual of RHA experience by new consultants is low, and has important implications for establishing an experienced RHA consultant workforce.

Long-term implant survival following hemiarthroplasty for fractured neck of femur.

Aims: Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty. Methods: Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 September 1999 and 31 December 2020 who underwent hemiarthroplasty for the treatment of a hip fracture with the following implants were included: a cemented monoblock Exeter Trauma Stem (ETS), cemented Exeter V40 with a bipolar head, a monoblock Thompsons prosthesis (Cobalt/Chromium or Titanium), and an Exeter V40 with a Unitrax head. Overall and age-defined cumulative revision rates were compared over the ten years following surgery. Results: A total of 41,949 hemiarthroplasties were included. Exeter V40 with a Unitrax head was the most commonly used (n = 20,707, 49.4%). The overall rate of revision was small. A total of 28,201 patients (67.2%) were aged > 80 years. There were no significant differences in revision rates across all designs of hemiarthroplasty in patients of this age at any time. The revision rates for all designs were < 3.5%, three years postoperatively. At subsequent times the ETS and Exeter V40 with a bipolar head performed well in all age groups. The unadjusted ten-year mortality rate for the whole cohort was 82.2%. Conclusion: There was no difference in implant survival between all the designs of hemiarthroplasty in the first three years following surgery, supporting the selection of a cost-effective design of hemiarthroplasty for most patients with an intracapsular fracture of the hip, as determined by local availability and costs. Beyond this, the ETS and Exeter bipolar designs performed well in all age groups.

The value of national arthroplasty registry data in 2023.

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research.

Reoperation and revision rates at ten years after 1,312 cemented Thompson's hemiarthroplasties : any need to change to a different implant?

AIMS: Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson's hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. METHODS: Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. RESULTS: In total, 1,312 Thompson's hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. CONCLUSION: The Thompson's stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson's implant as a cost-effective option for frail hip fracture patients.Cite this article: Bone Jt Open 2022;3(9):710-715.

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man.

BACKGROUND: Prosthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings. METHODS: Adult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data. RESULTS: In total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001) CONCLUSION: This study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.

Simultaneous or Staged Bilateral Total Hip Arthroplasty? An Analysis of Complications in 14,460 Patients Using National Data.

BACKGROUND: Simultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality. METHODS: Hospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed. RESULTS: A total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units. CONCLUSION: These findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.

Conventional Versus Highly Cross-Linked Polyethylene in Primary Total Knee Replacement: A Comparison of Revision Rates Using Data from the National Joint Registry for England, Wales, and Northern Ireland.

BACKGROUND: There is evidence to support the use of highly cross-linked polyethylene (HXLPE) in patients undergoing total hip arthroplasty. However, the benefits for those undergoing total knee arthroplasty are uncertain, with conflicting reports based on previous cohort analyses. The purpose of the present study was to compare the revision rates following primary total knee arthroplasty with use of HXLPE as compared with conventional polyethylene (CPE) using data from the National Joint Registry (NJR) for England, Wales and Northern Ireland. METHODS: We performed a retrospective analysis of primary total knee arthroplasties recorded in the NJR from 2003 to 2014. Cobalt-chromium (CoCr)-CPE and CoCr-HXLPE bearing surfaces were compared using all-cause revision, aseptic revision, and septic revision as end points. Survival analyses were conducted using rates per 100 years observed, Kaplan-Meier survival estimates, and Cox regression hazard ratios (HRs) adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), lead surgeon grade, and implant constraint. Secondary analyses compared the most commonly used HXLPEs (Zimmer Prolong, DePuy XLK, and Stryker X3) against CPE for the 3 most common total knee arthroplasty systems (NexGen, PFC Sigma, and Triathlon). RESULTS: In the present study of 550,658 total knee arthroplasties, the unadjusted aseptic revision rates were significantly lower following procedures performed with CPE (n = 513,744) as compared with those performed with HXLPE total knee replacements (n = 36,914) (0.29 [95% confidence interval (CI), 0.28 to 0.30] compared to 0.38 [95% CI, 0.35 to 0.42], p < 0.01). The 10-year HR associated with CPE was 0.4 (95% CI, 0.1 to 0.8, p = 0.03). There were no significant differences between the adjusted revision rates of HXPLE compared with CPE in individual analyses of the most common total knee arthroplasty systems. However, for the subset of patients who were both <60 years of age and had a BMI of >35 kg/m, the "second-generation" Stryker X3 HXLPE demonstrated significantly better survival than its respective CPE, with CPE having an HR of 2.6 (95% CI, 1.2 to 5.9) (p = 0.02). CONCLUSIONS: Alternative bearings are marketed as having improved wear properties over traditional CoCr-CPE. This registry-based analysis demonstrated no overall survival benefit of HXLPE after a maximum duration of follow-up of 12 years. Because of their increased cost, the routine use of HXLPE bearings may not be justified. However, they may have a role in specific "higher demand" groups such as patients <60 years of age and/or those with a BMI of >35 kg/m. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete list of levels of evidence.

Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731,214 cases using National Joint Registry data.

AIMS: Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients. MATERIALS AND METHODS: Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients. RESULTS: Of 731 214 TKAs, 15 295 (2.1%) were implanted with plain cement and 715 919 (97.9%) with ALBC. There were 13 391 revisions; 2391 were performed for infection. After adjusting for other variables, ALBC had a significantly lower risk of revision for any cause (hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; p < 0.001). ALBC was associated with a lower risk of revision for all aseptic causes (HR 0.85, 95% CI 0.77 to 0.95; p < 0.001) and revisions for infection (HR 0.84, 95% CI 0.67 to 1.01; p = 0.06). The results were similar when BMI was added into the model, and in a subanalysis where surgeons using only ALBC over the entire study period were excluded. Prosthesis survival at ten years for TKAs implanted with ALBC was 96.3% (95% CI 96.3 to 96.4) compared with 95.5% (95% CI 95.0 to 95.9) in those implanted with plain cement. On a population level, where 100 000 TKAs are performed annually, this difference represents 870 fewer revisions at ten years in the ALBC group. CONCLUSION: After adjusting for a range of variables, ALBC was associated with a significantly lower risk of revision in this registry-based study of an entire nation of primary cemented knee arthroplasties. Using ALBC does not appear to increase midterm implant failure rates. Cite this article: Bone Joint J 2019;101-B:1331-1347.

Implant Optimisation for Primary Hip Replacement in Patients over 60 Years with Osteoarthritis: A Cohort Study of Clinical Outcomes and Implant Costs Using Data from England and Wales.

BACKGROUND: Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis. METHODS AND FINDINGS: Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data. RESULTS: EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285). Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients. CONCLUSIONS: Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.

Changes in surface topography at the TKA backside articulation following in vivo service: a retrieval analysis.

PURPOSE: With the advent of modular total knee arthroplasty (TKA) systems, backside wear at the articulation between the ultra-high-molecular-weight-polyethylene (UHMWPE) component undersurface and the tibial baseplate has received increasing attention as a source of clinically significant polyethylene wear debris. The aim of this study was to investigate the reciprocating interface at the TKA undersurface articulation using profilometry after in vivo service. Our null hypothesis was that there would be no discernible pattern or relationship between the metal tibial baseplate and UHMWPE surface profile. METHODS: A nanoscale analysis of thirty retrieved fixed-bearing TKA explants was performed. Surface roughness (Sa) and skewness (Ssk) were measured on both the UHMWPE component undersurface and the tibial baseplate of explants using a non-contacting profilometer (1 nm resolution). Four pristine unimplanted components of two different designs (Stryker Kinemax and DePuy PFC) were examined for control purposes. RESULTS: Mean explant baseplate surface roughness was 1.24 µm (0.04-3.01 µm). Mean explant UHMWPE undersurface roughness was 1.16 µm (0.23-2.44 µm). Each explant had an individual roughness pattern with unique baseplate and undersurface UHMWPE surface roughness that was different from, but closely related to, surface topography observed in control implants of the same manufacturer and design. Following in vivo service, UHMWPE undersurface showed changes towards a negative skewness, demonstrating that wear is occurring at the backside interface. CONCLUSION: In vivo loading of the TKA prosthesis leads to measurable changes in surface profile at the backside articulation, which appear to be dependent on several factors including implant design and in vivo duration. These findings are consistent with wear occurring at this surface. Findings of this study would support the use of a polished tibial tray over an unpolished design in total knee arthroplasty with the goal of reducing PE wear by means of providing a smoother backside countersurface for the UHMWPE component.

No functional benefit of larger femoral heads and alternative bearings at 6 months following primary hip replacement.

BACKGROUND AND PURPOSE: There has been a recent trend towards the use of greater femoral head sizes in an attempt to improve function and enhance stability after primary hip replacement. This has been associated with the use of alternative bearings, theoretically to reduce wear and improve implant longevity. METHODS: We examined the influence of these variables on patient-reported outcome measures (PROMs) for a consecutive series of primary hip replacements using National Joint Registry (NJR) and PROMs-linked data. To minimize the confounding influence of implant design factors, the single most commonly used brand in England and Wales (DePuy Corail Pinnacle) was examined. Improvement in patient hip-specific outcomes (Oxford hip score, OHS), general health outcomes (Euroqol, EQ-5D), and rates of self-reported complications (bleeding, wound problems, re-admission, and reoperation) were compared for different head sizes (28-mm, 32-mm, and 36-mm) and bearings (metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC)), adjusting for differences in case mix. RESULTS: At a mean follow-up of 7 months, improvements in OHS and EQ5D index were similar for 28-mm and 36-mm heads. A 32-mm head was associated with poorer function (OHS: 20, 99% CI: 19-21, p = 0.002; EQ5D index: 0.39, 99% CI: 0.36-0.42, p = 0.004), although these small differences may not be of clinical importance. There were no statistically significant benefits of either CoP or CoC bearings compared to a MoP bearing. Complication rates were similar within comparisons of head sizes or bearings. INTERPRETATION: In this short-term study, we did not find any functional benefits of larger head sizes or alternative bearings, after adjusting for other influences. We question their use in routine primary hip replacement given the lack of evidence of improved long-term survival in the literature.

Have cementless and resurfacing components improved the medium-term results of hip replacement for patients under 60 years of age?

BACKGROUND AND PURPOSE: The optimal hip replacement for young patients remains unknown. We compared patient-reported outcome measures (PROMs), revision risk, and implant costs over a range of hip replacements. METHODS: We included hip replacements for osteoarthritis in patients under 60 years of age performed between 2003 and 2010 using the commonest brand of cemented, cementless, hybrid, or resurfacing prosthesis (11,622 women and 13,087 men). The reference implant comprised a cemented stem with a conventional polyethylene cemented cup and a standard-sized head (28- or 32-mm). Differences in implant survival were assessed using competing-risks models, adjusted for known prognostic influences. Analysis of covariance was used to assess improvement in PROMs (Oxford hip score (OHS) and EQ5D index) in 2014 linked procedures. RESULTS: In males, PROMs and implant survival were similar across all types of implants. In females, revision was statistically significantly higher in hard-bearing and/or small-stem cementless implants (hazard ratio (HR) = 4) and resurfacings (small head sizes (< 48 mm): HR = 6; large head sizes (≥ 48 mm): HR = 5) when compared to the reference cemented implant. In component combinations with equivalent survival, women reported significantly greater improvements in OHS with hybrid implants (22, p = 0.006) and cementless implants (21, p = 0.03) (reference, 18), but similar EQ5D index. For men and women, National Health Service (NHS) costs were lowest with the reference implant and highest with a hard-bearing cementless replacement. INTERPRETATION: In young women, hybrids offer a balance of good early functional improvement and low revision risk. Fully cementless and resurfacing components are more costly and do not provide any additional benefit for younger patients.

The impact of body mass index on patient reported outcome measures (PROMs) and complications following primary hip arthroplasty.

Influence of BMI upon patient outcomes and complications following THA was examined across a national cohort of patients. Outcomes were compared by BMI groups (19.0-29.9kg/m(2) [reference], 30.0-34.9kg/m(2) [obese class I], 35.0kg/m(2)+ [obese class II/III]), adjusted for case-mix differences. Obese class I patients had a significantly smaller improvement in OHS (18.9 versus 20.5, P<0.001) and a greater risk of wound complications (odds ratio [OR]=1.57, P=0.006). For obese class II/III patients, there were significantly smaller improvements in OHS and EQ-5D index (P<0.001), and greater risk of wound complications (P=0.006), readmission (P=0.001) and reoperation (P=0.003). Large improvements in patient outcomes were seen irrespective of BMI, although improvements were marginally smaller and complication rates higher in obese patients.

Pulmonary embolism following ankle fractures treated without an operation - an analysis using National Health Service data.

The majority of ankle fractures are stable and can be treated without an operation, most commonly with cast immobilisation. Based on concerns regarding the risk of a venous thromboembolic event (VTE) while immobilised, there is currently debate as to whether these patients should receive VTE prophylaxis for the duration of treatment. Rates of pulmonary embolism (PE) in this patient group are unknown. This retrospective cohort study was designed to identify patients treated without an operation for ankle fracture and determine the occurrence of PE and inpatient mortality within 90 days of injury using the English National Health Service administrative databases. Logistic regression models were used to assess the influence of age, gender and Charlson co-morbidity score on these outcomes. We identified 14777 adult patients over a 54-month period (April 2007-September 2011) that met our linkage and inclusion criteria (isolated, unilateral closed ankle fracture that did not require hospitalisation). Mean age was 46.4 years (range 18-99) and the majority had a Charlson 0 score (97.7%). There were 32 (0.22%) PEs within 90 days of the fracture (including in one patient who subsequently died). After adjustment, Charlson score of ≥1 was associated with a greater risk of PE (Odds ratio = 11.97, p < 0.001) compared to Charlson 0. Risk for these patients was 2.08%. In total, fifteen patients (0.11%) died in hospital within 90 days. Pulmonary embolism is rare following ankle fractures treated without an operation. Patients with multiple co-morbidities are at a higher risk. Based on this evidence, an ankle fracture treated without an operation does not appear to be an indication for routine VTE prophylaxis.

A comparison of surgical approaches for primary hip arthroplasty: a cohort study of patient reported outcome measures (PROMs) and early revision using linked national databases.

The posterior and lateral approaches to primary hip arthroplasty were compared using national data from England and Wales. Specific component combinations of the most commonly used cemented and cementless implant brands were analysed separately. There was no significant difference between the approaches for all-cause revision risk (cemented: P = 0.726, cementless: P = 0.295) and revision for dislocation (P = 0.176, P = 0.695) at 12 months following 37,593 procedures, after adjusting for patient and surgical variables. Analysis of 3881 linked episodes found the posterior approach was associated with significantly higher improvement in function (Oxford Hip Score: 20.8 versus 18.9, P < 0.001 (cemented procedures); 21.7 versus 20.2, P = 0.008 (cementless), EQ5D index: 0.416 versus 0.383, P = 0.003; 0.431 versus 0.384, P = 0.003). The posterior approach may offer a functional benefit (albeit small clinically), without increased revision risk.

Early PROMs following total knee arthroplasty--functional outcome dependent on patella resurfacing.

Patella resurfacing during primary total knee arthroplasty (TKA) remains controversial. Variation in published results for patella resurfacing may potentially be explained by differences in design between TKA brands. We interrogated NJR-PROMs data to ascertain whether there is an early functional benefit to resurfacing the patella, both overall and for each of the five most popular primary knee designs through use of the Oxford Knee Score. A total of 8103 resurfaced TKAs and 15,290 nonresurfaced TKAs were studied. There was a large variation in the proportion of knees undergoing patella resurfacing by brand (Nexgen=16% versus Triathlon=52%). Patellar resurfacing did not significantly influence the magnitude of improvement in overall knee function or anterior knee-specific function irrespective of TKA brand or for cruciate retaining versus sacrificing designs.

Increasing age and female gender are associated with early knee replacement following arthroscopy.

PURPOSE: Early knee replacement following arthroscopy may be perceived as a failure of the original treatment and thus a poor use of resources. Factors that may be associated with increased risk of early replacement were explored in this study. METHODS: All adult patients who underwent planned knee arthroscopy in a national cohort over a 6-month period in 2005 were extracted from the administrative hospital admissions database and linked to determine whether and when a knee replacement occurred on the same knee within the subsequent 5 years. A combination of survival analysis and mixed effect modelling was used to investigate risk factors for replacement. RESULTS: There were a total of 20,556 arthroscopies, of which 2,161 (10.6%) subsequently underwent knee replacement. For patients under 60 years, female gender (62.1% higher risk, p < 0.001) and increasing age (12.7% increased risk per increasing year of age, p < 0.001) were significant associations for requiring knee replacement, after risk adjusting. Of those aged ≥60, 12.7% (576) had undergone a replacement at 1 year following arthroscopy. Females (33% higher risk), increasing age (7.3% increased risk per increasing year of age, p < 0.001) and hypertension (1,600% higher risk, p < 0.001) were significant predictors. The risk associated with increased age was not proportional for the older age group, with risk declining as time passed from arthroscopy, indicating other factors were influencing progression to knee replacement. CONCLUSIONS: The predictors of early knee replacement following arthroscopy were female sex, age over 60 years and hypertension, irrespective of type of operation. This work may contribute to national recommendations regarding the provision of arthroscopy for patients over 60 years. LEVEL OF EVIDENCE: III.

Cemented hemiarthroplasty or hip replacement for intracapsular neck of femur fracture? A comparison of 7732 matched patients using national data.

BACKGROUND: The treatment of choice for intracapsular neck of femur (NOF) fractures in younger, more active patients remains unknown. Some surgeons advocate total hip replacement (THR). AIM: This study aimed to compare complications following THR and hemiarthroplasty using the Hospital Episode Statistics (HES) database in England. METHOD: Dislocation and revision rates were extracted for all patients with NOF fracture who underwent either cemented hemiarthroplasty or cemented THR between January 2005 and December 2008. To make a 'like for like' comparison all 3866 THR patients were matched to 3866 hemiarthroplasty patients (from a total of 41,343) in terms of age, sex and Charlson score. RESULTS AND CONCLUSION: Eighteen-month dislocation was significantly higher in the THR group (2.4% vs. 0.5%, odds ratio (OR) 3.90 (2.99-5.05), p<0.001). This difference was sustained at the 4-year stage (2.9% vs. 0.9%, OR 3.18 (1.58-6.94), p=0.001) in a subset of patients with longer follow-up. There was no significant difference in revision rate up to 4 years (1.8% vs. 2.1%, OR 0.85 (0.46-1.55), p=0.666). In this national analysis of matched patients short- and medium-term dislocation rates following THR were significantly higher than following cemented hemiarthroplasty, without any difference in revision rates at 4 years. The low risk of dislocation may be acceptable in order to experience the apparent functional benefits of THR.