Best practice guidelines for clinical and radiological assessment of patients with femoroacetabular impingement. Results from the ISHA International Delphi Consensus Project-Phase 2.

In 2018, the International Society for Hip Preservation Surgery (ISHA) initiated a series of Delphi consensus studies to identify the global hip preservation community's current opinion on best practices for different facets of hip preservation surgery. Arthroscopic procedures to treat hip pathologies, such as femoroacetabular impingement syndrome (FAIS) are now established in mainstream orthopaedic practice. This study establishes recommendations for the investigation of patients with suspected FAIS. The investigation has focused on the three phases of the diagnostic process-patient history, physical examination and special investigations. Our expert panel consisted of 174 international orthopaedic surgeons with expertise in hip preservation surgery, thereby making recommendations generalisable across the globe. After three rounds of survey and analysis with 174 participants per round, our study achieved consensus at a minimum agreement threshold of 80.0% on 55 statements pertaining to the assessment of patients with FAIS. We encourage our junior and senior hip arthroscopy colleagues internationally to consider these statements both to standardize the clinical and radiological assessment of patients with FAIS and to aid in the design of future research.

A Simple Technique to Remove an Incarcerated Ceramic Liner in Revision Hip Arthroplasty.

Extraction of a well-fixed ceramic liner during revision total hip arthroplasty can be technically challenging, particularly when acetabular fixation screws prevent en bloc removal of the shell and insert without causing collateral damage to the adjacent pelvic bone. It is also important to remove the ceramic liner intact, as ceramic debris left in the joint may cause third body wear with premature articular wear of the revised implants. We describe a novel technique to extract an incarcerated ceramic liner when previously described strategies prove ineffective. Knowledge of this technique will help surgeons avoid unnecessary damage to the acetabular bone and optimize prospects for stable implantation of revision components.

The impact of COVID-19 pandemic on the mortality and morbidity of patients undergoing trauma surgery: a report from the UK Corona TRAUMA Surge (UKCoTS) study.

PURPOSE: To assess the impact of the COVID-19 pandemic on the outcomes of the patients who underwent trauma surgery during the peak of the pandemic. METHODS: The UKCoTS collected the postoperative outcomes of consecutive patients who underwent trauma surgery across 50 centres during the peak of the pandemic (April 2020) and during April 2019. RESULTS: Patients who were operated on during 2020 were less likely to be followed up within a 30-day postoperative period (57.5% versus 75.6% p <0.001). The 30-day mortality rate was significantly higher during 2020 (7.4% versus 3.7%, p <0.001). Likewise, the 60-day mortality rate was significantly higher in 2020 than in 2019 (p <0.001). Patients who were operated on during 2020 had lower rates of 30-day postoperative complications (20.7% versus 26.4%, p <0.001). CONCLUSIONS: Postoperative mortality was higher during the first wave of the COVID-19 pandemic compared to the same period in 2019, but with lower rates of postoperative complications and reoperation.

In search of excellence.

A little while ago, I had the opportunity to spend some time in the operating room (theatre) of one of the world's most experienced and technically skilful hip arthroscopists. How I wish I had made the effort to visit this surgeon earlier in my career and how I regret that there are still so many surgeons I have failed to visit. Every surgeon who has allowed me into their operating room has shown me something that has enhanced my practice and learning to execute their manoeuvres always adds to the pleasure of surgical practice.

Global impact of COVID-19 on surgeons and team members (GlobalCOST): a cross-sectional study.

OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

The composition of cell-based therapies obtained from point-of-care devices/systems which mechanically dissociate lipoaspirate: a scoping review of the literature.

PURPOSE: Cell-based therapies using lipoaspirate are gaining popularity in orthopaedics due to their hypothesised regenerative potential. Several 'point-of-care' lipoaspirate-processing devices/systems have become available to isolate cells for therapeutic use, with published evidence reporting their clinical relevance. However, few studies have analysed the composition of their 'minimally-manipulated' cellular products in parallel, information that is vital to understand the mechanisms by which these therapies may be efficacious. This scoping review aimed to identify devices/systems using mechanical-only processing of lipoaspirate, the constituents of their cell-based therapies and where available, clinical outcomes. METHODS: PRISMA extension for scoping reviews guidelines were followed. MEDLINE, Embase and PubMed databases were systematically searched to identify relevant articles until 21st April 2022. Information relating to cellular composition and clinical outcomes for devices/systems was extracted. Further information was also obtained by individually searching the devices/systems in the PubMed database, Google search engine and contacting manufacturers. RESULTS: 2895 studies were screened and a total of 15 articles (11 = Level 5 evidence) fulfilled the inclusion criteria. 13 unique devices/systems were identified from included studies. All the studies reported cell concentration (cell number regardless of phenotype per millilitre of lipoaspirate) for their devices/systems (range 0.005-21 × 106). Ten reported cell viability (the measure of live cells- range 60-98%), 11 performed immuno-phenotypic analysis of the cell-subtypes and four investigated clinical outcomes of their cellular products. Only two studies reported all four of these parameters. CONCLUSION: When focussing on cell concentration, cell viability and MSC immuno-phenotypic analysis alone, the most effective manual devices/systems were ones using filtration and cutting/mincing. However, it was unclear whether high performance in these categories would translate to improved clinical outcomes. Due to the lack of standardisation and heterogeneity of the data, it was also not possible to draw any reliable conclusions and determine the role of these devices/systems in clinical practice at present. LEVEL OF EVIDENCE: Level V Therapeutic.

Artificial intelligence for image analysis in total hip and total knee arthroplasty : a scoping review.

AIMS: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are. METHODS: The Embase, MEDLINE, and PubMed libraries were systematically searched to identify relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley framework were followed. Study quality was assessed using a modified Methodological Index for Non-Randomized Studies tool. AI performance was reported using either the area under the curve (AUC) or accuracy. RESULTS: Of the 455 studies identified, only 12 were suitable for inclusion. Nine reported implant identification and three described predicting risk of implant failure. Of the 12, three studies compared AI performance with orthopaedic surgeons. AI-based implant identification achieved AUC 0.992 to 1, and most algorithms reported an accuracy > 90%, using 550 to 320,000 training radiographs. AI prediction of dislocation risk post-THA, determined after five-year follow-up, was satisfactory (AUC 76.67; 8,500 training radiographs). Diagnosis of hip implant loosening was good (accuracy 88.3%; 420 training radiographs) and measurement of postoperative acetabular angles was comparable to humans (mean absolute difference 1.35° to 1.39°). However, 11 of the 12 studies had several methodological limitations introducing a high risk of bias. None of the studies were externally validated. CONCLUSION: These studies show that AI is promising. While it already has the ability to analyze images with significant precision, there is currently insufficient high-level evidence to support its widespread clinical use. Further research to design robust studies that follow standard reporting guidelines should be encouraged to develop AI models that could be easily translated into real-world conditions. Cite this article: Bone Joint J 2022;104-B(8):929-937.

Criteria for the Operating Room Confirmation of the Diagnosis of Hip Instability: The Results of an International Expert Consensus Conference.

PURPOSE: The purpose of this study was to establish an international expert consensus on operating room findings that aid in the diagnosis of hip instability. METHODS: An expert panel was convened to build an international consensus on the operating room diagnosis/confirmation of hip instability. Seventeen surgeons who have published or lectured nationally or internationally on the topic of hip instability were invited to participate. Fifteen panel members completed a pre-meeting questionnaire and agreed to participate in a 1-day consensus meeting on May 15, 2021. A review of the literature was performed to identify published intraoperative reference criteria used in the diagnosis of hip instability. Studies were included for discussion if they reported and intraoperative findings associated with hip instability. The evidence for and against each criteria was discussed, followed by an anonymous voting process. For consensus, defined a priori, items were included in the final criteria set if at least 80% of experts agreed. RESULTS: A review of the published literature identified 11 operating room criteria that have been used to facilitate the diagnosis of hip instability. Six additional criteria were proposed by panel members as part of the pre-meeting questionnaire. Consensus agreement was achieved for 8 criteria, namely ease of hip distraction under anesthesia (100.0% agreement), inside-out pattern of chondral damage (100.0% agreement), location of chondral damage on the acetabulum (93.3% agreement), pattern of labral damage (93.3% agreement), anteroinferior labrum chondral damage (86.7% agreement), perifoveal cartilage damage (97.6% agreement), a capsular defect (86.7% agreement), and capsular status (80.0% agreement). Consensus was not achieved for 9 items, namely ligamentum teres tear (66.7% agreement), arthroscopic stability tests (46.7% agreement), persistent distraction after removal of traction (46.7% agreement), findings of examination under anesthesia (46.7% agreement), the femoral head divot sign (40.0% agreement), inferomedial synovitis (26.7% agreement), drive-through sign (26.7% agreement), iliopsoas irritation (26.7% agreement) and ligamentum teres-labral kissing lesion (13.3% agreement). All experts agreed on the final list of 8 criteria items reaching consensus. CONCLUSION: This expert panel identified 8 criteria that can be used in the operating room to help confirm the diagnosis of hip instability. LEVEL OF EVIDENCE: Level V expert opinion.

Comparison of the accuracy of 2D and 3D templating methods for planning primary total hip replacement: a systematic review and meta-analysis.

There are advocates of both two-dimensional (2D) and three-dimensional (3D) templating methods for planning total hip replacement. The aim of this study was to compare the accuracy of implant size prediction when using 2D and 3D templating methods for total hip arthroplasty, as well as to compare the inter- and intra-observer reliability in order to determine whether currently available methods are sufficiently reliable and reproducible. Medline, EMBASE and PubMed were searched to identify studies that compared the accuracy of 2D and 3D templating for total hip replacement. Results were screened using the PRISMA flowchart and included studies were assessed for their level of evidence using the Oxford CEBM criteria. Non-randomized trials were critically appraised using the MINORS tool, whilst randomized trials were assessed using the CASP RCT checklist. A series of meta-analyses of the data for accuracy were also conducted. Ten studies reported that 3D templating is an accurate and reliable method of templating for total hip replacement. Six studies compared 3D templating with 2D templating, all of which concluded that 3D templating was more accurate, with three finding a statistically significant difference. The meta-analyses showed that 3D CT templating is the most accurate method. This review supports the hypothesis that 3D templating is an accurate and reliable method of preoperative planning, which is more accurate than 2D templating for predicting implant size. However, further research is needed to ascertain the significance of this improved accuracy and whether it will yield any clinical benefit.

The accuracy and reliability of preoperative digital 2D templating in prosthesis size prediction in uncemented versus cemented total hip arthroplasty: a systematic review and meta-analysis.

The purpose of this study was to compare the accuracy and the inter- and intra-observer reliability of preoperative digital 2D templating in prosthesis size prediction for the planning of cemented or uncemented THA.This study was registered in the NIHR PROSPERO database (ID: CRD42020216649) and conducted according to the PRISMA guidelines. A search of electronic databases in March 2021 found 29 papers overall. The quality of evidence was assessed using the IHE Quality Appraisal of Case Series Studies Checklist and the CASP Randomised Controlled Trials Checklist. A meta-analysis was conducted, and the accuracy was presented as proportions and the inter- and intra-observer reliability were measured using intraclass correlation coefficients (ICC).Accuracy within one prosthesis size (±1) for cemented stems was 0.89 (95% confidence interval (CI) 0.83-0.95), cemented cups 0.78 (95% CI 0.67-0.89), uncemented stems 0.74 (95% CI 0.66-0.82) and uncemented cups 0.73 (95% CI 0.67-0.79) (test of group differences: p = 0.010). Inter-observer reliability (ICC) for uncemented cups was 0.88 (95% CI 0.85-0.91), uncemented stems 0.86 (95% CI 0.81-0.91), cemented stems 0.69 (95% CI 0.54-0.84) and cemented cups 0.68 (95% CI 0.55-0.81) (test of group differences: p = 0.004). Due to lack of data, intra-observer reliability (ICC) could only be calculated for uncemented prostheses, which for the stems was 0.90 (95% CI 0.88-0.92) and for the cups was 0.87 (95% CI 0.83-0.90) (test of group differences: p = 0.124).The accuracy of preoperative digital templating is greater for cemented prostheses, but the inter-observer reliability is greater for uncemented prostheses. The intra-observer reliability showed a high level of agreement for uncemented prostheses. Cite this article: EFORT Open Rev 2021;6:1020-1039. DOI: 10.1302/2058-5241.6.210048.

Nickel hypersensitivity and skin patch testing in total hip replacement surgery: a systematic review.

Approximately 60,000 cemented femoral stems are implanted in the UK each year with the majority being manufactured from stainless steel containing 10-15% nickel. Nickel hypersensitivity has been reported in up to 13% of the general population and there is a concern that nickel hypersensitivity might adversely affect the outcome of total hip replacement (THR). We reviewed the current literature on the potential link between nickel hypersensitivity and THR complications, and the usefulness of patch testing.We conducted a literature search in PubMed, MEDLINE and EMBASE databases. The level of evidence and the quality of the selected studies were assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the Methodological Index for Non-Randomised Studies tool, respectively.Twenty-six studies met the inclusion criteria, reporting on 1852 patients who underwent primary or revision THR. All studies detailed skin patch testing and recorded prevalence of nickel hypersensitivity from 1.5% to 33.3%. Five studies reported a rise in Nickel hypersensitivity following THR, while four reported a decreased prevalence post-operatively. Eight studies concluded that metal hypersensitivity could have developed following THR, while seven studies did not support a link between metal hypersensitivity and THR complications. Four of the studies recommended routine patch testing pre-operatively, but three others concluded that routine patch testing was not indicated.We have not identified a link between nickel hypersensitivity and THR complications, and the role of patch testing remains unclear. Further large-scale studies would be required to investigate this relationship and to clarify the role of patch testing in facilitating implant selection. Cite this article: EFORT Open Rev 2021;6:825-838. DOI: 10.1302/2058-5241.6.210051.

The Medial Rotation Knee replacement: Clinical and radiological results of a multi-centre surveillance study at five years.

BACKGROUND: The Medial Rotation Knee (MRK) has one of the lowest revision rates of total knee replacement designs in the National Joint Registry. While survival is one metric of performance of implants, patient-reported outcomes, combined with clinical and radiological evaluation, allow more complete analysis. We report the five-year results of a prospective, multi-centre surveillance study of the MRK. METHODS: A 16-surgeon, three-centre series of 520 total knee replacements were performed in 486 patients, comprising 182 males and 304 females. The mean age was 70.3 years (46-96) and BMI 29.5 kg/m2 (18-57). Study subjects were given questionnaires pre-operatively, at six months, and annually thereafter. Clinical and radiological reviews were scheduled pre-operatively, at six months, three and five years. RESULTS: At five years, 395 of the original 486 patients (427 of 520 knees) remained under active review. Twenty-six patients (27 knees) had withdrawn, 44 patients/knees had died and one was excluded. Thirteen patients (14 knees) were lost to follow-up, but were not revised. Seven knees were revised, equating to a survival probability of 98.6% at five years. There were significant improvements in mean Oxford Knee Score (21.23-35.79), EQ-5D (0.440-0.694) and Knee Society Score (Knee 43.00-83.97; Function 49.45-71.39). Of the radiographs available for evaluation, radiolucency was identified in 25 knees (14.6%) with one case of osteolysis of the tibial component. CONCLUSION: In addition to excellent survivorship, mid-term patient-reported, clinical and radiological results at five years are satisfactory, and consistent with other medial pivot designs.

The preoperative Oxford Knee Score is an independent predictor of achieving a postoperative ceiling score after total knee arthroplasty.

AIMS: The primary aim of this study was to assess whether the postoperative Oxford Knee Score (OKS) demonstrated a ceiling effect at one and/or two years after total knee arthroplasty (TKA). The secondary aim was to identify preoperative independent predictors for patients that achieved a ceiling score after TKA. METHODS: A retrospective cohort of 5,857 patients undergoing a primary TKA were identified from an established arthroplasty database. Patient demographics, body mass index (BMI), OKS, and EuroQoL five-dimension (EQ-5D) general health scores were collected preoperatively and at one and two years postoperatively. Logistic regression analysis was used to identify independent preoperative predictors of patients achieving postoperative ceiling scores. Receiver operating characteristic curve was used to identify a preoperative OKS that predicted a postoperative ceiling score. RESULTS: The ceiling effect was 4.6% (n = 272) at one year which increased significantly (odds ratio (OR) 40.3, 95% confidence interval (CI) 30.4 to 53.3; p < 0.001) to 6.2% (n = 363) at two years, when defined as those with a maximal score of 48 points. However, when the ceiling effect was defined as an OKS of 44 points or more, this increased to 26.3% (n = 1,540) at one year and further to 29.8% (n = 1,748) at two years (OR 21.6, 95% CI 18.7 to 25.1; p < 0.001). A preoperative OKS of 23 or more and 22 or more were predictive of achieving a postoperative ceiling OKS at one and two years when defined as a maximal score or a score of 44 or more, respectively. CONCLUSION: The postoperative OKS demonstrated a small ceiling effect when defined by a maximal score, but when defined by a postoperative OKS of 44 or more the ceiling effect was moderate and failed to meet standards. The preoperative OKS was an independent predictor of achieving a ceiling score. Cite this article: Bone Joint J 2020;102-B(11):1519-1526.

Three-year results of a polycarbonate urethane acetabular bearing in total hip arthroplasty.

BACKGROUND: Polycarbonate urethane (PCU) is a bearing surface with a lower modulus of elasticity than polyethylene or ceramic and is thought to more closely replicate the tribology of native hyaline cartilage. The purpose of this study was to determine the clinical outcomes with the use of PCU in elective total hip arthroplasty (THA). METHODS: We carried out a prospective observational study in which 157 patients underwent elective THA with a metal-on-PCU hip system. Patients had radiographic follow-up at 6 months and 3 years after surgery. Oxford Hip Scores and EuroQol scores were obtained annually and Harris Hip Scores were obtained at 6 months and 3 years after surgery. RESULTS: 180 hips were implanted, of which, 149 hips reached 3-year review with no revisions. There was an increase in Harris Hip Scores, Oxford Hip Scores and EuroQol scores (p < 0.001). 12 patients (12 hips) reported painless hip squeaking. There were no dislocations and no other adverse events were reported. CONCLUSION: Our results showed satisfactory survivorship and improvements in patient reported outcomes with metal on PCU THA. Long-term data are still being collected to confirm these findings. We recommend further tribological research into the squeaking phenomenon we observed.

Validation of revision data for total hip and knee replacements undertaken at a high volume orthopaedic centre against data held on the National Joint Registry.

BACKGROUND: With over 2.35 million records, the National Joint Registry (NJR) is the largest arthroplasty registry in the world. It provides a powerful tool to monitor implant survivorship and influence different surgical strategies. To date, little work has been undertaken to investigate the validity of the 'Reason for Revision' recorded in Consultant Outcome Reports on the NJR. METHODS: The NJR was queried to identify all revisions on the THR performed at a single centre over an 11-year period. Review and validation of 'Reason for Revision' for each case was undertaken using radiological imaging studies, pathology, histology, microbiology and electronic medical records. RESULTS: Of the 22,046 primary total hip replacements (THR) and total knee replacements (TKR) undertaken by 23 surgeons at our hospital, over an 11-year period, 1.35% (297) were subsequently reported to the NJR as revised. Discrepancies in reporting to the NJR were identified for 41 cases (25.63%) for THR and 28 (20.40%) cases for TKR. Revision for infection was under-reported for both THR and TKR by 1.88% and 3.65% respectively. Reporting of adverse soft tissue reaction to particulate debris for THR was unreported by 11%. Progressive arthritis following a TKR was unreported by 6.56%. All the cases reported as 'other' (8.75% for THRs and 3.65% for TKRs) were reclassified to the most appropriate 'reason for revision' category. The 'reason for revision' data is recorded to the NJR with findings at the time of surgery. It is some days before microbiology and histology reports become available and source data is not always updated. CONCLUSION: If an average of 23% wrong data entry at a highly organised institution is replicated throughout the UK, a formal process to validate primary and revision data submitted to the NJR should be considered. Local scrutiny, review and validation of revision data are all vital to optimise the value of the NJR. Accurate data recorded to the NJR is imperative to provide safe and effective improvements in orthopaedic surgery.