One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6–20.7) and 32.3 (95% CI 27.3–38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58–5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.Electronic supplementary materialThe online version of this article (10.1007/s10654-018-0377-9) contains supplementary material, which is available to authorized users.

The classification and management of aseptic loosening of total hip arthroplasty remains a distinct challenge to the modern orthopaedic surgeon. The aim of this study was to assess the inter-observer and intra-observer reliability of commonly used classification systems for the assessment of bone stock loss in revision hip surgery. Radiographs of 23 femoral and 32 acetabular components in 30 patients were assessed using the Paprosky, AAOS and Endo-Klinik classification systems. A novel classification system was introduced and also used to assess the radiographs. Assessment was undertaken by 3 surgeons on 2 separate occasions and the inter- and intra- observer reliability calculated. The novel classification system showed a good to very good intra-observer reliability for both femoral and acetabular components (0.77-1.0; p<0.001), performing better than the other systems assessed. The novel femoral system demonstrated moderate to good inter-observer agreement (0.46-0.73), performing as well as the Paprosky (0.63-0.80) and AAOS (0.63-0.68) femoral systems. The novel acetabular system demonstrated fair to moderate inter-observer reliability (0.35-0.51) performing better than the AAOS acetabular classification (0.07-0.10) and as well as the Paprosky acetabular classification system (0.59-0.60). We propose this novel system as an alternative method for assessing bone stock loss in revision hip surgery.

Thermal damage to host bone is a possible source of compromise of fixation in patients undergoing cemented total hip replacement (THR). Data on the subject to date are derived from mathematical modelling powered by animal studies. The aim of this study was to assess the effect of cement thickness on osteocyte viability in a population of patients undergoing cemented THR.An in vivo model was designed and validated by means of a finite element analysis. During standard hip joint replacement in 14 patients, the femoral necks were exposed before final resection to the heat of a curing cement mantle equivalent to 2.5 (Group 1) or 5 mm (Group 2) in vivo in the cemented acetabulum. Matched controls were collected for each patient. Osteocyte counts and viability were assessed by means of haematoxylin and eosin (H&E) stain and lactate dehydrogenase (LDH) assay. Ex vivo experiments were performed to determine the extent of thermal insult.H&E staining proved unreliable for assessing thermal insult in the short term. The LDH assay was reliable and demonstrated a significant reduction in osteocyte viability to a depth of 2.19 mm in group 1 and 9.19 mm in group 2. There was a significant difference between the groups at all depths. The ex vivo experiments revealed thermoclines indicating that host bone in the population undergoing cemented THR is more sensitive to the thermal insult delivered by curing polymethylmethacrylate cement than previously believed.This thermal insult may weaken the fixation between bone and cement and contribute towards aseptic loosening, the commonest cause of failure of THRs.

The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.

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Background Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium. Methods We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models. Results Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92–0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02–1.10) and return to original residence (OR=1.04, CI=1.00–1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups. Conclusions Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

Background Patellar resurfacing is optional during total knee replacement (TKR). Some surgeons always resurface the patella, some never resurface, and others selectively resurface. Which resurfacing strategy provides optimal outcomes is unclear. We assessed the effectiveness of patellar resurfacing, no resurfacing, and selective resurfacing in primary TKR. Methods A systematic review and meta-analysis was performed. MEDLINE, Embase, Web of Science, The Cochrane Library, and bibliographies were searched to November 2021 for randomised-control trials (RCTs) comparing outcomes for two or more resurfacing strategies (resurfacing, no resurfacing, or selective resurfacing) in primary TKR. Observational studies were included if limited or no RCTs existed for resurfacing comparisons. Outcomes assessed were patient reported outcome measures (PROMs), complications, and further surgery. Study-specific relative risks [RR] were aggregated using random-effects models. Quality of the evidence was assessed using GRADE. Results We identified 33 RCTs involving 5,540 TKRs (2,727 = resurfacing, 2,772 = no resurfacing, 41 = selective resurfacing). One trial reported on selective resurfacing. Patellar resurfacing reduced anterior knee pain compared with no resurfacing (RR = 0.65 (95% CI = 0.44–0.96)); there were no significant differences in PROMs. Resurfacing reduced the risk of revision surgery (RR = 0.63, CI = 0.42–0.94) and other complications (RR = 0.54, CI = 0.39–0.74) compared with no resurfacing. Quality of evidence ranged from high to very low. Limited observational evidence (5 studies, TKRs = 215,419) suggested selective resurfacing increased the revision risk (RR = 1.14, CI = 1.05–1.22) compared with resurfacing. Compared with no resurfacing, selective resurfacing had a higher risk of pain (RR = 1.25, CI = 1.04–1.50) and lower risk of revision (RR = 0.92, CI = 0.85–0.99). Conclusions Level 1 evidence supports TKR with patellar resurfacing over no resurfacing. Resurfacing has a reduced risk of anterior knee pain, revision surgery, and complications, despite PROMs being comparable. High-quality RCTs involving selective resurfacing, the most common strategy in the UK and other countries, are needed given the limited observational data suggests selective resurfacing may not be effective over other strategies.