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Background Total knee arthroplasty (TKA) with mechanical alignment (MA) aims to achieve neutral limb alignment in all patients, whereas TKA with functional alignment (FA) aims to restore native, patient-specific anatomy and knee kinematics by manipulating bone resections and fine-tuning implant positioning. The objective of this study is to determine the optimal alignment technique in TKA by comparing patient satisfaction, functional outcomes, implant survivorship, complications, and cost-effectiveness in MA TKA versus FA TKA. Robotic technology will be used to execute the planned implant positioning and limb alignment with high-levels of accuracy in all study patients. Methods and analysis This prospective double-blinded randomised control trial will include 100 patients with symptomatic knee osteoarthritis undergoing primary robotic arm-assisted TKA. Following informed consent, patients will be randomised to MA TKA (the control group) or FA TKA (the investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning and limb alignment, gait, implant stability, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether FA TKA provides superior outcomes compared to MA TKA. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Surrey Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This is the first study to describe the use of robotic technology to achieve FA TKA, and the only existing clinical trial comparing robotic MA TKA versus robotic FA TKA. The findings of this study will enable an improved understanding of the optimal alignment technique in TKA for achieving high-levels of patient satisfaction, improving functional outcomes, increasing implant survivorship, improving cost-effectiveness, and reducing complications. Registration Clinical Trials.gov , NCT04092153 . Registered on 17 September 2019.

Background Extended trochanteric osteotomy (ETO) in revision hip arthroplasty provides direct access to the femoral medullary canal and facilitates removal of implants and re-implantation. This study looks at objective outcomes of ETO from a systematic review of the literature and a case series of revision total hip arthroplasty (THA) cases with ETOs from the authors’ local institution. Methods (1) The National Institutes of Health (NIH) national library of medicine was searched for studies related to ETO and the preferred reporting items for systematic reviews and meta-analyses (PRISMA) technique were followed. (2) Case series of 23 revision THAs with ETOs from University College London Hospital (UCLH) were retrospectively analyzed with a minimum of 2-year follow-up for radiological outcomes. Results (1) The main revision THAs diagnoses were aseptic loosening (880/1,386; 63.4%), prosthetic joint infection (PJI) (301/1,386; 21.7%) and periprosthetic THA fractures (78/1,386; 5.6%). Other diagnoses, including non-specified reasons for THA revision in the chosen studies, accounted for 9.2% (127/1,386). The total mean was a union rate of 95.2%, an infection eradication rate of 91.6%, a femoral stem subsidence rate of 16.6%, with the rate of subsidence more than 5 mm being 10.7%. ETO proximal migration was reported in 7.8% of ETOs; however, it rarely required re-attachment (0.9%). Intraoperative fracture during revision THA with ETO was reported to be at a rate of 5%; while postoperative femoral fracture rate was at 7.8%. (2) All 24 cases had radiographic union at 3 to 6 months and there was no reported femoral stem subsidence. Conclusion The overall outcome of this literature review provides moderate-quality evidence indicating that ETO provides safe outcome for revision THAs in single and 2-stage revision surgeries with low ETO non-union, femoral stem subsidence, greater trochanter (GT) proximal migration and fracture rates in the different diagnoses groups of revision THA at over 2-year follow up. In the case series group, there was radiographic union of all ETOs with no reported femoral stem subsidence or periprosthetic fractures.

PurposeA new fluted, titanium, monobloc stem with a three degree taper has been designed in an attempt to overcome the challenges associated with femoral reconstruction in the setting of extensive bone loss. The aim of this study was to report its early clinical and radiographic outcomes.MethodsThis is a retrospective review of prospectively collected data carried out at a single institution between Jan 2017 and Dec 2019. Forty-three femoral revisions were performed using a new tapered, fluted, titanium, monobloc (TFTM) revision stem. Complications, clinical and radiographic data were obtained from medical records and a locally maintained database. Clinical outcomes were assessed using the Oxford Hip Score (OHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). All post-operative radiographs were analysed for subsidence, osteolysis and femoral cortical bone remodelling.ResultsMean follow-up was 24 months (range 8–42 months). Subsidence of 1.2 mm was noted in one patient. No cases of clinically significant subsidence (> 10 mm) were observed. At final follow-up, a statistically significant improvement was noted in functional outcome scores. The mean OHS preoperatively and at final follow-up were 24 (SD 13) and 42 (SD15). p = 0.04 mean difference 18 (95% CI 15–22). The mean WOMAC scores preoperatively and at final follow-up were 62 (SD23) and 88 (SD7) respectively (p < 0.001, mean difference 26; 95% CI 21–34). No stem fractures were noted within the follow-up period.ConclusionPositive early clinical and radiological outcomes have been observed with this tapered, fluted, titanium, monobloc stem. Based on these results, this implant may be considered as a viable option in the majority of uncemented femoral revisions.

Background Revision total hip arthroplasties (RTHA) are associated with a higher complication rate than primary total hip arthroplasties (THA), and therefore it is important for patients to have realistic expectations regarding outcomes. The aim of this literature review was to gather and summarize the available evidence on patients’ expectations following RTHA. Methods A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar, Web of Science and Embase from inception to November 2023. Articles assessing patient expectations for RTHA were included. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies. A qualitative analysis was performed involving the summarization of study characteristics and outcomes. Results The search strategy generated 7,450 references, of which 5 articles met the inclusion criteria. Methodological quality scores ranged from 7–10. Patients had high expectations concerning future walking ability, pain and implant longevity relative to actual postoperative outcomes. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction ( r  = 0.46–0.47). Only two studies assessed the fulfillment of patient expectations. Great variability was seen in the measurement of expectations. Conclusion Patients undergoing RTHA appeared to have high expectations for pain and functionality compared to postoperative outcomes. However, there was a paucity of high-quality data in this area, limiting the accuracy of the conclusion. Further research is needed, that emphasizes developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools for patient expectations.

Background An increasing number of patients undergoing hip or knee replacement have chronic diseases. It has been suggested that the presence of chronic diseases may affect access to this type of surgery in the English National Health Service (NHS). We examined the access to hip and knee replacement surgery in patients with and without chronic diseases according to preoperative patient-reported pain, functional status and symptom duration. Methods We analysed data of 640,832 patients who had hip or knee surgery between 2009 and 2016 in England. Multivariable regression was used to estimate the impact of 11 chronic diseases on severity of joint problems as measured on a scale from 0 to 48 by Oxford Hip (OHS) and Knee Scores (OKS) just before surgery and on likelihood of long-standing joint problems (> 5 years pre-operatively). Results Patients with chronic diseases reported more severe joint problems than patients without (OHS differences ranged from 1.1 [95% CI 0.93, 1.2] to 2.5 [95% CI 2.3, 2.7] and OKS differences from 0.5 [95% CI 0.3, 0.7] to 2.6 [95% CI 2.4, 2.7] for the 11 chronic diseases) but the differences remain small. When analysed separately, patients with chronic diseases reported both more severe pain and poorer functional status. Six chronic diseases in hip patients and two in knee patients increased the likelihood that they had long-standing joint problems. The severity of joint problems just before surgery increased with the number of chronic diseases (OHS differences; one chronic disease (1.5 [95% CI 1.4, 1.5]) to four or more (5.8 [95% CI 5.6, 6.0])). Conclusions Patients with chronic diseases reported more severe joint problems immediately before hip or knee replacement surgery suggesting they have hip or knee replacement later in the course of their joint disease.

Background This study examined the agreement between patient-reported chronic diseases and hospital administrative records in hip or knee arthroplasty patients in England. Methods Survey data reported by 676,428 patients for the English Patient Reported Outcome Measures (PROMs) programme was linked to hospital administrative data. Sensitivity and specificity of 11 patient-reported chronic diseases were estimated with hospital administrative data as reference standard. Results Specificity was high (> 90%) for all 11 chronic diseases. However, sensitivity varied by disease with the highest found for ‘diabetes’ (87.5%) and ‘high blood pressure’ (74.3%) and lowest for ‘kidney disease’ (18.8%) and ‘leg pain due to poor circulation’ (26.1%). Sensitivity was increased for diseases that were given as specific examples in the questionnaire (e.g. ‘parkinson’s disease’ (65.6%) and ‘multiple sclerosis’ (69.5%), compared to ‘diseases of the nervous system’ (20.9%)). Conclusions Patients can give information about the presence of chronic diseases that is consistent with chronic diseases derived from hospital administrative data if the description in the patient questionnaire is precise and if the disease is familiar to most patients and has significant impact on their life. Such patient questionnaires need to be validated before they are used for research and service evaluation projects.

Background Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning during total hip arthroplasty. The objective of this study is to compare the accuracy of implant positioning, restoration of hip biomechanics, patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications in conventional manual total hip arthroplasty (CO THA) versus robotic-arm assisted total hip arthroplasty (RO THA). Preoperative pelvic computerised tomography (CT) scans will be used to create patient-specific, virtual, three-dimensional reconstructions for surgical planning in both treatment groups. Methods and analysis This prospective randomised controlled trial will include 60 patients with symptomatic hip osteoarthritis undergoing primary THA. Following informed consent, patients will be randomised to CO THA (control group) or RO THA (investigation group) at a ratio of 1:1 using an online random number generator. Observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to the accuracy of implant positioning, hip biomechanics, postoperative rehabilitation, clinical progress, functional outcomes, cost-effectiveness, and complications. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. Intention to treat relates to the allocated treatment (CO THA or RO THA), and per-protocol refers to the actual treatment received by the patient. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Bromley Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This study compares a comprehensive and robust range of clinical, functional, and radiological outcomes in CT-planned CO THA versus CT-planned RO THA. The findings of this study will enable an improved understanding of the differences in CO THA versus RO THA with respect to patient satisfaction, functional outcomes, implant survivorship, cost-effectiveness, and complications. Trial registration ClinicalTrials.gov NCT04095845 . Registered on 19 September 2019

Introduction Extensive acetabular bone loss and poor bone quality are two key challenges often encountered in revision total hip arthroplasty. A new 3D-printed porous acetabular shell has been made available with the option to insert multiple variable-angle locking screws. We sought to evaluate the early clinical and radiological outcomes of this construct. Methods A retrospective review of patients operated by two surgeons was performed in a single institution. Fifty-nine revision hip arthroplasties were performed in 55 patients (34 female; mean age 68.8 ± 12.3 years) for Paprosky defects I ( n  = 21), IIA/B ( n  = 22), IIC ( n  = 9), III ( n  = 7) between February 2018 and January 2022 using the novel porous titanium acetabular shell and multiple variable angle locking screws. Postoperative clinical and radiographic outcomes were locally maintained. Patient-reported outcome measures collected included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Hip Score, and the 12-item Short Form Survey. Results After a mean follow-up of 25.7 ± 13.9 months, two cases of shell migration were noted. One patient had a failed constrained mechanism and received revision to a cemented dual mobility liner. No other acetabular shells showed any evidence of radiographic loosening at the final follow-up. Preoperatively, 21 defects were classified as Paprosky grade I, 19 grade IIA, 3 grade IIB, 9 IIC, 4 grade IIIA, and 3 IIIB. The mean postoperative WOMAC function score was 84 (SD 17), WOMAC (stiffness) 83 (SD 15), WOMAC (pain) 85 (SD 15), and WOMAC (global) 85 (SD 17). The mean postoperative OHS was 83 (SD 15), and mean SF-12 physical score was 44 (SD 11). Conclusion The additional augmentation of porous metal acetabular shells with multiple variable-angle locking screws provides reliable initial fixation with good clinical and radiological outcomes in the short term. Further studies are needed to establish the medium- and long-term outcomes. Level of evidence IV.

Background The direct superior approach (DSA) is a minimally invasive modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoint tendon during total hip arthroplasty (THA). The objective of this study is to compare patient satisfaction, functional outcomes, accuracy of implant positioning, component stability, gait, cost-effectiveness, and complications in the DSA versus PA for THA. Methods and analysis This prospective double-blinded randomised control trial will include 80 patients with symptomatic hip osteoarthritis undergoing primary THA. Following informed consent, patients will be randomised to THA using the PA (control group) or DSA (investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning, gait analysis on force plate treadmill, implant migration with radiosteriometric analysis, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether the DSA provides improved outcomes compared to the PA for THA. Evaluation of study outcomes in DSA and PA will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Fulham Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This study compares a comprehensive and robust range of clinical, functional, and radiological outcomes in THA performed using the PA versus DSA. The findings of this study will provide an improved understanding of the differences in the PA versus DSA for THA with respect to patient satisfaction, functional outcomes, implant survivorship, gait, cost-effectiveness, and complications. Trial registration ClinicalTrials.gov, NCT04191993 . Registered on 10 December 2019

Significantly reduced distance between the ischium and the femur can result in symptomatic hip pain as a result of impingement. We present the case of a 16-year-old boy who presented with groin pain which had been affecting him for a year and a half following an innocuous football injury. Plain radiograph revealed a chronic apophyseal avulsion fracture of the ischium with excessive callus formation. CT scan and MRI revealed that the bony protuberance was responsible for symptomatic ischiofemoral impingement. In this case, he was successfully treated with non-operative management involving slow re-introduction to exercise. An unusual example of acquired ischiofemoral impingement, unrelated to surgery or significant trauma, this case highlights the need to consider such a diagnosis in otherwise unexplained groin pain.