Long-term effect of botulinum toxin A on the hip and spine in cerebral palsy: A national retrospective cohort study in Taiwan.

OBJECTIVES: To investigate the effect of botulinum toxin A (BTA) on the development of hip dislocation and scoliosis, surgical rates for hip and spine, and mortality in cerebral palsy (CP). STUDY DESIGN: A cohort study was conducted using CP data from a Taiwan National Insurance Health Research Database. Diagnoses were defined using the International Classification of Diseases codes, 9th revision. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis and adjusted for the following variables: BTA injection, sex, age, severities of CP, comorbidities, location, urbanization level, and level of care. RESULTS: A total of 1,405 CP children (670 female vs. 735 male), 281 in the BTA group and 1,124 in the controls, were followed-up for a mean of 5 years 4 months. There were no significant differences in the outcomes in both groups, in the incidence rates of hip dislocation and scoliosis, nor in the surgical rates for hip and spine surgery. Mortality rate in the BTA group was 0.49 times lower than that in the controls (p = 0.001). Moderate to severe types of CP had higher incidence rates of hip dislocation, scoliosis, hip surgery, spine surgery, and mortality. CONCLUSION: Moderate to severe types of CP had poorer outcomes in all aspects, including a higher risk of hip dislocation, scoliosis, surgical rate for hip and spine, and mortality. Although BTA injection in children with CP proved to not significantly reduce hip dislocation and scoliosis, it is considered safe as an anti-spasticity treatment and may be beneficial for survival.

Long-term results in the patients with traumatic hip fracture-dislocation: Important prognostic factors.

BACKGROUND: Traumatic hip dislocation with or without acetabular fractures can lead to various outcomes of the hip. Long-term follow-up studies on traumatic hip dislocation are few. We conducted a retrospective study of the treatment and long-term outcomes in patients with hip dislocation to determine prognostic factors. METHODS: From 2001 to 2016, we enrolled 38 patients in our study. All the patients had been diagnosed through radiography or computed tomography. Emergent closed reduction was performed initially. We hypothesized that poor outcomes, including osteonecrosis and traumatic osteoarthritis, are related to specific factors. RESULTS: All the patients had posterior dislocation initially. Closed reduction or open reduction due to irreducible after closed reduction was performed within 6 hours of dislocation in most patients. In total, nine patients had poor outcomes of the hip, including osteonecrosis and traumatic osteoarthritis and total hip arthroplasty. Specific factors that lead to poor outcomes were patient age and timing of reduction. CONCLUSION: Although end results in severe traumatic hip dislocation are disappointing, conservatism in applying the secondary reconstructive procedure is desirable. In our series, crucial factors for long-term prognosis were patient age and timing of hip reduction.

Rotational acetabular osteotomy for symptomatic hip dysplasia in patients younger than 21 years of age: seven- to 30-year survival outcomes.

AIMS: The aim of this study was to report the long-term results of rotational acetabular osteotomy (RAO) for symptomatic hip dysplasia in patients aged younger than 21 years at the time of surgery. PATIENTS AND METHODS: We evaluated 31 patients (37 hips) aged younger than 21 years at the time of surgery retrospectively. There were 29 female and two male patients. Their mean age at the time of surgery was 17.4 years (12 to 21). The mean follow-up was 17.9 years (7 to 30). The RAO was combined with a varus or valgus femoral osteotomy or a greater trochanteric displacement in eight hips, as instability or congruence of the hip could not be corrected adequately using RAO alone. RESULTS: The mean Merle d'Aubigné clinical score improved significantly from 15.4 to 17.2 (p < 0.0001). The mean centre-edge (CE) angle improved from -2.6° to 26°, the mean acetabular roof angle improved from 3.0° to 5.2°, and the mean head lateralization index improved from 0.68 to 0.62. Progression of radiological osteoarthritis (OA) was seen in seven hips, but no patient underwent total hip arthroplasty. CONCLUSION: RAO is an effective form of correction for a severely dysplastic hip in adolescent and young adult patients. Cite this article: Bone Joint J 2019;101-B:390-395.

Outcomes After Metal-on-metal Hip Revision Surgery Depend on the Reason for Failure: A Propensity Score-matched Study.

BACKGROUND: Metal-on-metal hip replacement (MoMHR) revision surgery for adverse reactions to metal debris (ARMD) has been associated with an increased risk of early complications and reoperation and inferior patient-reported outcome scores compared with non-ARMD revisions. As a result, early revision specifically for ARMD with adoption of a lower surgical threshold has been widely recommended with the goal of improving the subsequent prognosis after ARMD revisions. However, no large cohorts have compared the risk of complications and reoperation after MoMHR revision surgery for ARMD (an unanticipated revision indication) with those after non-ARMD revisions (which represent conventional modes of arthroplasty revision). QUESTIONS/PURPOSES: (1) Does the risk of intraoperative complications differ between MoMHRs revised for ARMD compared with non-ARMD indications? (2) Do mortality rates differ after MoMHRs revised for ARMD compared with non-ARMD indications? (3) Do rerevision rates differ after MoMHRs revised for ARMD compared with non-ARMD indications? (4) How do implant survival rates differ after MoMHR revision when performed for specific non-ARMD indications compared with ARMD? METHODS: This retrospective observational study involved all patients undergoing MoMHR from the National Joint Registry (NJR) for England and Wales subsequently revised for any indication between 2008 and 2014. The NJR achieves high levels of patient consent (93%) and linked procedures (ability to link serial procedures performed on the same patient and hip; 95%). Furthermore, recent validation studies have demonstrated that when revision procedures have been captured within the NJR, the data completion and accuracy were excellent. Revisions for ARMD and non-ARMD indications were matched one to one for multiple potential confounding factors using propensity scores. The propensity score summarizes the many patient and surgical factors that were used in the matching process (including sex, age, type of primary arthroplasty, time to revision surgery, and details about the revision procedure performed such as the approach, specific components revised, femoral head size, bearing surface, and use of bone graft) using one single score for each revised hip. The patient and surgical factors within the ARMD and non-ARMD groups subsequently became much more balanced once the groups had been matched based on the propensity scores. The matched cohort included 2576 MoMHR revisions with each study group including 1288 revisions (mean followup of 3 years for both groups; range, 1-7 years). Intraoperative complications, mortality, and rerevision surgery were compared between matched groups using univariable regression analyses. Implant survival rates in the non-ARMD group were calculated for each specific revision indication with each individual non-ARMD indication subsequently compared with the implant survival rate in the ARMD group using Cox regression analyses. RESULTS: There was no difference between the ARMD and non-ARMD MoMHR revisions in terms of intraoperative complications (odds ratio, 0.97; 95% confidence interval [CI], 0.59-1.59; p = 0.900). Mortality rates were lower after ARMD revision compared with non-ARMD revision (hazard ratio [HR], 0.43; CI, 0.21-0.87; p = 0.019); however, there was no difference when revisions performed for infection were excluded from the non-ARMD indication group (HR, 0.69; CI, 0.35-1.37; p = 0.287). Rerevision rates were lower after ARMD revision compared with non-ARMD revision (HR, 0.52; CI, 0.36-0.75; p < 0.001); this difference persisted even after removing revisions performed for infection (HR, 0.59; CI, 0.40-0.89; p = 0.011). Revisions for infection (5-year survivorship = 81%; CI, 55%-93%; p = 0.003) and dislocation/subluxation (5-year survivorship = 82%; CI, 69%-90%; p < 0.001) had the lowest implant survival rates when compared with revisions for ARMD (5-year survivorship = 94%; CI, 92%-96%). CONCLUSIONS: Contrary to previous observations, MoMHRs revised for ARMD have approximately half the risk of rerevision compared with non-ARMD revisions. We suspect worldwide regulatory authorities have positively influenced rerevision rates after ARMD revision by recommending that surgeons exercise a lower revision threshold and that such revisions are now being performed at an earlier stage. The high risk of rerevision after MoMHR revision for infection and dislocation is concerning. Infected MoMHR revisions were responsible for the increased mortality risk observed after non-ARMD revision, which parallels findings in non-MoMHR revisions for infection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Long-term Mortality After Revision THA.

BACKGROUND: Long-term mortality after primary THA is lower than in the general population, but it is unknown whether this is also true after revision THA. QUESTIONS/PURPOSES: We examined (1) long-term mortality according to reasons for revision after revision THA, and (2) relative mortality trends by age at surgery, years since surgery, and calendar year of surgery. METHODS: This retrospective study included 5417 revision THAs performed in 4532 patients at a tertiary center between 1969 and 2011. Revision THAs were grouped by surgical indication in three categories: periprosthetic joint infections (938; 17%); fractures (646; 12%); and loosening, bearing wear, or dislocation (3833; 71%). Patients were followed up until death or December 31, 2016. The observed number of deaths in the revision THA cohort was compared with the expected number of deaths using standardized mortality ratios (SMRs) and Poisson regression models. The expected number of deaths was calculated assuming that the study cohort had the same calendar year, age, and sex-specific mortality rates as the United States general population. RESULTS: The overall age- and sex-adjusted mortality was slightly higher than the general population mortality (SMR, 1.09; 95% CI, 1.05-1.13; p < 0.001). There were significant differences across the three surgical indication subgroups. Compared with the general population mortality, patients who underwent revision THA for infection (SMR, 1.35; 95% CI, 1.24-1.48; p < 0.001) and fractures (SMR, 1.23; 95% CI, 1.11-1.37; p < 0.001) had significantly increased risk of death. Patients who underwent revision THA for aseptic loosening, wear, or dislocation had a mortality risk similar to that of the general population (SMR, 1.01; 95% CI, 0.96-1.06; p = 0.647). The relative mortality risk was highest in younger patients and declined with increasing age at surgery. Although the relative mortality risk among patients with aseptic indications was lower than that of the general population during the first year of surgery, the risk increased with time and got worse than that of the general population after approximately 8 to 10 years after surgery. Relative mortality risk improved with time after revision THA for aseptic loosening, wear, or dislocation. CONCLUSIONS: Shifting mortality patterns several years after surgery and the excess mortality after revision THA for periprosthetic joint infections and fractures reinforce the need for long-term followup, not only for implant survival but overall health of patients having THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Interventions for Improving Hip Resurfacing Outcomes in Women: A High-Volume, Retrospective Study.

BACKGROUND: Women seeking surgical intervention for their hip disorders will often find total hip arthroplasty (THA) presented as their only option. THA, when compared with hip resurfacing arthroplasty, removes substantially more bone-stock, limits range-of-motion, exhibits increased dislocation risk, and presents greater overall 10-year mortality rate. Despite these risks, most surgeons continue to select against women for hip resurfacing because registries notoriously report inferior survivorship when compared with men and THA. METHODS: We investigated the reasons for why resurfacing arthroplasty devices survive poorly in women to develop interventions which might improve hip resurfacing outcomes in women. Using these findings, we developed a series of surgical interventions to treat the underlying issues. Herein, we compare 2 study groups: women who received hip resurfacings before (group 1) and after (group 2) these interventions. RESULTS: Eight-year implant survivorship substantially improved from 89.6% for group 1 to 97.7% for group 2. Adverse wear-related failure, femoral component loosening, and acetabular component loosening were all significantly reduced in group 2, which we attribute to the implementation of our relative acetabular inclination limit guidelines, use of uncemented femoral fixation, and selection of the Tri-Spike acetabular component for supplemental fixation, respectively. Kaplan-Meier implant survivorship curves, grouped into 2-year time intervals, show that the disparity in failure rates between men and women is diminishing. CONCLUSION: When experienced surgeons use refined and proper surgical technique, women show promise as excellent candidates for hip resurfacing as an alternative treatment for their debilitating hip conditions.

Ten-year survival rate after rotational acetabular osteotomy in adulthood hip dysplasia.

BACKGROUND: Rotational acetabular osteotomy (RAO) is an effective joint-preserving surgical treatment for adulthood hip dysplasia (AHD). Despite sufficient correction of acetabular dysplasia, some patients still experience osteoarthritis (OA) progression and require total hip arthroplasty (THA). The purposes of the current study were to investigate the survival rate and the risk factors for OA progression or THA requirement after RAO and to explore whether acetabular overcorrection relates to OA progression. METHODS: Fifty-six patients (65 hips, mean age: 36.5 ± 11.7 years) with AHD who underwent RAO and were followed up for >10 years (mean: 15.0 ± 3.2 years) were enrolled in this study. A Kaplan-Meier survival analysis was performed to assess the non-OA progression rate and THA-free survival rate of RAO during the 10-year follow-up. To analyze the risk factors for OA progression and THA requirement, the Cox proportional hazards regression analysis was performed. RESULTS: No OA progression was found in 76.7% of the patients, and THA was not required in 92.3% during the 10-year follow-up. By multivariate regression analysis, older age at the time of surgery was a risk factor for both OA progression (hazard ratio [HR] = 1.047, 95% confidence interval [CI] = 1.005-1.091) and THA requirement (HR = 1.293, 95% CI = 1.041-1.606). CONCLUSION: RAO is an effective surgical procedure for symptomatic patients with AHD that prevents OA progression and protects the hips from undergoing THA. However, older patients have a higher risk for both OA progression and THA requirement.

Displaced intracapsular neck of femur fractures in the elderly: bipolar hemiarthroplasty may be the treatment of choice; a case control study.

Management of the mobile elderly patient who sustains an intra-capsular neck of femur fracture remains controversial. Current evidence is mixed as to whether total hip arthroplasty (THA), which confers higher surgical and dislocation risk, is significantly superior in function and in reduced rates of reoperation when compared to bipolar hemi-arthroplasty. A group of 110 patients with an intra-capsular NOF fracture who had undergone either THA or Bipolar hemi-arthroplasty and were still alive at the time of follow up were retrospectively identified and matched using the National Hip Fracture Database. Matching criteria included ASA, age, sex, pre-op mobility, pre-op AMTS and source of admission. Follow up was by postal questionnaire. Mean follow up was 24 months in both groups (Range; Bipolar 12-36 months, THA 12-38 months). There was no significant difference in pre-operative Tonnis grade, postoperative Oxford Hip Score (OHS) or Short Form 36 (SF-36) scores between the two groups. 12 dislocations in 5 patients occurred in the THA group and none in the bipolar group. 33/55 Bipolar patients were discharged to their own home compared to 35/55 in the THA group. None of the bipolar hemi-arthroplasties were revised to THA. Higher complication rates were experienced in the THA group with no increase in function.

Predictors and outcomes of treatment in hip hemiarthroplasty dislocation.

INTRODUCTION: Dislocation following hip hemiarthroplasty (HHA), its incidence, predictors, treatment outcomes and mortality were investigated in a single centre series. METHODS: The prospectively collected data on neck of femur fracture admissions compiled over 11 years were reviewed. Place of residence, place of fall, past medical history, intraoperative factors (grade of surgeon, delay in surgery, type of implant and operative time), postoperative complications and mortality were compared between patients who suffered a dislocation and those who did not. In the dislocation group, the mean number of dislocations, reduction method, type and fate of implant, and mortality were investigated. RESULTS: Prospective data on 8,631 admissions were collected; 41% of these were managed with a HHA. The dislocation rate was 0.76%. A delay in surgery of >24 hours was associated with a fourfold increase in the dislocation risk. The majority (81%) of dislocations occurred in the first six weeks and closed manipulation was the definitive treatment in only 23% of the cases. The mortality rate was not increased following HHA dislocation. CONCLUSIONS: The delay in surgery was the most important predictor of HHA dislocation. Closed reduction was associated with a high failure rate. While an initial attempt at closed reduction for a first dislocation is recommended, for redislocators, we recommend early exploration/revision as an alternative to repeat manipulations.

[Dislocated femoral neck fractures in geriatric patients. One-year follow-up]. / Die dislozierte Schenkelhalsfraktur des geriatrischen Patienten. Einjahresergebnisse.

BACKGROUND: In geriatric patients with Pauwels II and III type femoral neck fractures, endoprosthesis is the treatment of choice. PURPOSE: What are the long-term results after surgery? MATERIALS AND METHODS: In 2007 and 2008, 104 public health insurance (AOK) patients with displaced femoral neck fractures were treated surgically at our hospital. This number of included patients places us in the 97th percentile of all hospitals in Germany. Because the patients were publicly insured, all health information was available, including completely retrospective posthospital discharge, inpatient course, and 1-year mortality. RESULTS: A total of 77 women and 27 men (average age of 83.5 years) were included in the study. In addition to the femoral neck injury, 19% of the patients had an accompanying PCCL of 3, and 44% had a PCCL of 4. In addition, 16% suffered from heart failure, 23% from diabetes, and 19% from renal insufficiency. Time to surgery averaged 1-day postinjury. A dual head prosthesis (hemiprosthesis) was implanted in 81.4 % of cases, and a total joint prosthesis in 18.6%. Average operative time skin to skin was 53 min. Average inpatient stay was 14 days in 2007 and 12 days in 2008. On discharge, 71% of patients could ambulate independently. Of the remaining patients, two-thirds were already not ambulating independently prior to the fracture. Hospital mortality averaged 6% (national average 8.1%), and 30-day and 90-day mortality rates were 6% (n = 7) and 16.3% (n = 17). Within 1 year, 22.2% of patients (n = 23) died (national average 26.8%), with a natural mortality probability of 7.1% for an age of 83.5 years. Five patients were re-admitted, for contralateral prosthetic implantation (n = 4) or revision after periprosthetic fracture (n = 1), and 54.6% of patients were admitted to hospital during the year for other diseases (national average 53.8%). CONCLUSION: Endoprosthesis placement for displaced femoral neck fractures is a common, safe procedure. However, the patients are old and have comorbidities. Despite recent decreases in hospital mortality, the risk of death remains more than twice as high within 1 year than that for uninjured patients of the same age.

Associated lesions in posterior wall acetabular fractures: not a valid predictor of failure.

BACKGROUND: The general outcome of posterior wall acetabular fractures is still the source of discussion. Posterior wall fractures are recognized throughout the literature as being difficult to treat. The aim of the present study was to analyze in our own patients the relevance of the classical prognostic criteria for the outcome of isolated posterior wall fractures and those with associated lesions. MATERIALS AND METHODS: A prospective cohort of 33 consecutive patients treated operatively between 1996 and 2006 in a single level 1 trauma center for a posterior wall fracture of the acetabulum was analyzed retrospectively. Included were posterior wall acetabular fractures or associated posterior wall fractures, such as the combinations of posterior column with posterior wall, transverse with posterior wall, or T-shaped fracture with posterior wall fracture. Outcome measurement of the postoperative survival of the hip joints until the primary outcome reoperation (total hip replacement or fusion) and secondary outcome diagnosis of symptomatic osteoarthritis were performed. RESULTS: Twenty-six of the 33 patients with posterior wall fractures also had a dislocated joint. Twelve had isolated and 21 associated fractures. Six patients were reoperated with a THA (four patients within 2 years and one after 10 years), and one arthrodesis was done to treat a hematogenous septic arthritis in a degenerative hip joint. Secondary arthritis was observed in 10 patients. CONCLUSIONS: No difference was found between the outcome in cases of isolated posterior wall acetabular fracture and the outcome in those with associated lesions. The classical prognostic criteria were not found to be relevant to the outcome for our group.

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.

The twenty-year survivorship of two CDH stems with different design features.

UNLABELLED: Previous studies have shown that anatomical abnormalities of the femur in dislocated hips require the application of special CDH prosthesis for the reconstruction of the proximal femur in total hip arthroplasty (THA). We have retrospectively examined the clinical records and radiographs of 50 patients (67 hips) with low and high dislocations treated with THA in our institution, between January 1987 and December 1994. For the reconstruction of the femur, the stainless steel Charnley CDH stem, with polished surface, monoblock and collarless, was used in 32 hips; the Harris CDH stem, made of CoCr, precoated at the proximal part, modular and with collar was used in 35 hips. At the time of the latest follow-up, 11 Charnley and 6 Harris CDH stems had been revised for aseptic loosening at an average of 14 years (range 6-20) and 13 years (range 2-19), respectively. The survival rate at 20 years, with failure for aseptic loosening as the end point, was 63% for the Charnley and 78% for the Harris CDH stems. These results provide a basis for evaluation of newer techniques and designs. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

A prospective study of hip revision surgery using the Exeter long-stem prosthesis: function, subsidence, and complications for 57 patients.

BACKGROUND: The long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis. MATERIALS AND METHODS: Data was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images. RESULTS: Data from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57-1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction. CONCLUSION: Our subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.

Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial.

OBJECTIVE: To compare the functional results after displaced fractures of the femoral neck treated with internal fixation or hemiarthroplasty. DESIGN: Randomised trial with blinding of assessments of functional results. SETTING: University hospital. PARTICIPANTS: 222 patients; 165 (74%) women, mean age 83 years. Inclusion criteria were age above 60, ability to walk before the fracture, and no major hip pathology, regardless of cognitive function. INTERVENTIONS: Closed reduction and two parallel screws (112 patients) and bipolar cemented hemiarthroplasty (110 patients). Follow-up at 4, 12, and 24 months. MAIN OUTCOME MEASURES: Hip function (Harris hip score), health related quality of life (Eq-5d), activities of daily living (Barthel index). In all cases high scores indicate better function. RESULTS: Mean Harris hip score in the hemiarthroplasty group was 8.2 points higher (95% confidence interval 2.8 to 13.5 points, P=0.003) at four months and 6.7 points (1.5 to 11.9 points, P=0.01) higher at 12 months. Mean Eq-5d index score at 24 months was 0.13 higher in the hemiarthroplasty group (0.01 to 0.25, P=0.03). The Eq-5d visual analogue scale was 8.7 points higher in the hemiarthroplasty group after 4 months (1.9 to 15.6, P=0.01). After 12 and 24 months the percentage scoring 95 or 100 on the Barthel index was higher in the hemiarthroplasty group (relative risk 0.67, 0.47 to 0.95, P=0.02. and 0.63, 0.42 to 0.94, P=0.02, respectively). Complications occurred in 56 (50%) patients in the internal fixation group and 16 (15%) in the hemiarthroplasty group (3.44, 2.11 to 5.60, P<0.001). In each group 39 patients (35%) died within 24 months (0.98, 0.69 to 1.40, P=0.92) CONCLUSIONS: Hemiarthroplasty is associated with better functional outcome than internal fixation in treatment of displaced fractures of the femoral neck in elderly patients. TRIAL REGISTRATION: NCT00464230.

Acute coronary syndrome and myocardial infarction after orthopedic surgery in a patient with a recently placed drug-eluting stent.

Providing anesthesia care for patients who have recently undergone intracoronary drug-eluting stent placement presents unique clinical challenges. It is currently recommended that these patients remain on antiplatelet therapy until reendothelialization of the vessel has occurred (ie, 3-6 months, depending on the eluting medication) to prevent stent restenosis. In the setting of urgent or emergent surgery, it may not be possible to wait until a full course of antiplatelet therapy has been completed. We report an unusual case of postoperative acute coronary syndrome in a gentleman who underwent intracoronary stenting 7 weeks before nonelective revision hip arthroplasty. To our knowledge, this is the first case in the anesthesia literature to report postoperative cardiac morbidity after recent drug-eluting stent deployment.

Dislocated Thompson hemiarthroplasty--the management of the recurrent dislocator.

Dislocation of a Thompson hemiarthroplasty of the hip is a serious complication with a high mortality rate. Previous papers have focused on surgical techniques to try and prevent dislocation. There is little in the literature on how to manage a patient after a dislocation. Patients with a dislocated Thompson hemiarthroplasty over a 5-year period from 1997 to March 2002 were analysed. Attempts were made to identify factors which may contribute to redislocation. Our strategies for preventing redislocation were evaluated. Of the 612 patients who received a Thompson hemiarthroplasty 23 patients (4%) dislocated. The average number of dislocations per patient was 2.4. Thirteen patients (57%) redislocated their prosthesis. Ten patients (43%) dislocated at least twice. Seven patients (30%) had either a total hip replacement, Girdlestone's procedure or the hip was left dislocated. Out of 15 patients fitted with an abduction brace 8 (60%) redislocated. Out of 8 patients treated with traction 6 (75%) redislocated. The 6-month mortality for patients suffering a dislocation was 7/23 (30%). If the prosthesis dislocates twice, the hip should be deemed unstable and consideration should be given to a revision procedure. Abduction braces and traction are ineffective in this condition and should be abandoned.

Reconstruction for chronic dislocation of the hip.

We analysed one surgeon's attempt to reconstruct the hip in 66 patients (84 hips) with chronic dislocation and to restore the height of the centre of rotation above the transverse teardrop line, the body-weight lever arm, the abductor lever arm, and the abductor angle to normal. The outcome was assessed using a patient profile at 0, 10 and 20 years, a clinical assessment of pain, mobility and the range of active movement. We measured the work done by active movement against gravity, radiological signs of loosening, migration and subsidence, and the need for revision. We used survival at ten years and revision as the endpoint. The incidence of complications was higher than in arthroplasty for primary osteoarthritis of the hip, but the outcome was considered satisfactory. The advantages of a flanged cemented socket were demonstrated. A custom-made, laterally reduced, Charnley extra small CDH femoral prosthesis was used in certain cases.