Introduction: Fat Embolism Syndrome (FES) poses a significant challenge in the management of polytrauma patients. While various theories and diagnostic criteria exist, optimal management with regard to time and mode of fixation remains elusive, particularly when FES manifests before orthopaedic intervention. Methods: This retrospective cohort study examined 24 patients with femur fractures and diagnosed FES at a Level 1 trauma centre. Data on demographics, injury details, interventions, time between diagnosis of FES and final fixation, length of ICU stay and outcomes were analyzed. Results: Fixation using unreamed nail was undertaken once key surgical eligibility indicators normalized, including oxygen levels on room air and oxygen, GCS, blood gas picture, hemoglobin, and lactate levels. Mean time to final fixation after diagnosis of FES of 11.17 days. The average postoperative ICU stay was 3.25 +/- 1.75 days. No mortality was noted in the post-operative period and up to 12-months in our cohort. We achieved a union rate >90% without the need for further intervention and no residual complications of FESS or postoperative mortality. Conclusion: FES is an unavoidable complication in femur fractures. Once suspected, such a patient should be managed in an ICU and deemed fit for fixation once haemoglobin, SpO2, lactate and GCS are stable. In our study, these parameters stabilized on the 11th day when we undertook nailing. Also, post-operatively, all our patients were kept in ICU for monitoring. Hence, using our protocol, we found unreamed nail to be a safe option in patients with established FES with femur fractures.

Introduction: Performing a revision THR (Total Hip Replacement) surgery is always challenging. Acetabular cup loosening and intrapelvic migration of hardware close to branches of significant vessels and pelvic viscera makes it more prone to inviting life-threatening complications.
Case Series: We present a case series with intrapelvic migration of hardware in which a CT angiogram was used to find the proximity of hardware to significant vessels. The hardware I e screws placed in acetabular cup were found to be in close proximity to the Internal Iliac artery or its branches esp. Superior Gluteal artery. A Temporary Balloon Catheter was placed in the Internal Iliac artery for temporary occlusion of vessels so as to prevent intraoperative vascular complication. A posterolateral approach was used in both cases to remove the intrapelvic cup. The balloon catheter was inflated just prior to removal of hardware and deflated after removal of cup. No Vascular complication was encountered in any case.
Conclusion: Revision THR comes with miscellaneous intraoperative complications. Pre-operative CT angiogram and temporary occlusion of desired vessels gives the surgeon a liberty to perform such surgeries with ease and also a window period to call the vascular surgeon in case of any vascular injury.

Purpose: Our aim is to find the functional and radiological outcome of TKA with plate osteosynthesis for acute unstable metaphyseal tibial stress fracture with severe osteoarthritis of knee. Methods: We have analysed acute unstable metaphyseal tibial stress fracture between April 2016 and March 2022. There were 8 patients included in the study group with a mean age of 65 years (range, 52–78 years). All patients had TKA with stem extension and augmentation with plate osteosynthesis and bone grafting. Demographic parameters, vitamin D, duration of complaints was retrieved from medical records. The functional outcome was assessed by the Knee Society Score (KSS) and Knee Society Functional Score (KSS-F). The radiological outcome analysed were tibio-femoral angle, grade of osteoarthritis and fracture union at the follow up. Results: The mean follow up was 3.1 years (range, 12 months to 71 months). The KSS and KSS-F, showed a significant improvement progressing from an initial value of 14.8 ± 6.8 and 23 ± 16.2 to 86 ± 8.7 and 85 ± 10.3, respectively (p < 0.05). All the fractures united at an average of 3.8 ± 1.4 months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. One patient had deep vein thrombosis and one had superficial wound dehiscence that was treated conservatively. Conclusion: In patients presenting with acute unstable metaphyseal tibial stress fracture with severe osteoarthritis, TKA with stem and plate osteosynthesis reliably results in fracture union and gives an excellent functional outcome.

Background: Metal implants have been preferentially used in THA due to its biocompatibility, mechanical stability and durability. Yet concerns have emerged regarding their potential to release metallic ions, leading to long-term adverse effects, including carcinogenicity. This study aimed to investigate the risk of cancer development in patients with orthopaedic metal implants in total hip arthroplasty (THA). Methods: Patients with THA conducted at a local tertiary implant centre from 2001–2008 were linked to the local cancer registry and followed up to the end of 2023. Standardized incidence ratios (SIRs) for cancer incidence and its confidence interval by Poisson distribution were calculated. Survival analysis was depicted using the Kaplan–Meier method, and the log-rank test was used to assess the differences across groups. Results: The study cohort included 388 patients and 53 cancers diagnosed during follow-up, at least 5 years post THA. All-site cancer risks were increased in patients with THA (SIR: 1.97; 95% CI: 1.48–2.46), validated with chi-square analysis (chi-square = 15.2551, N = 100,388, p < 0.01). A statistically significant increase in multiple site-specific cancers including haematological cancers were identified. Conclusions: Patients with THA were found to have an increased risk for cancer compared to the general population during a mean follow-up of 16 years.

Periprosthetic proximal femoral fractures (PPFFs) are one of the main causes for revision after total hip arthroplasty (THA), and are associated with some already known patient-/surgical-/implant-related risk factors. Despite the established increased risk of single and double-wedge femoral implants, the highest incidence in our institution has been observed with the anatomical cementless femoral component Anatomic Benoist Girard (ABG) II. The cumulative probability of PPFFs rose from 2.1% at 1 year to 6.5% at 10 years post-implantation, prompting comprehensive and multidisciplinary analysis. A novel parameter of preserved proximal femoral bone stock volume around implanted ABG II femoral stems (VPF) and the modelling technique for its evaluation on standing anteroposterior (AP) hip radiographs were introduced. Study was designed according to the standard protocol for matched case-control research. In the preliminary analysis, 5 age-/sex-/implant size-/surgeon-matched stratums, each comprising a case and 2 matched controls, were included. To calculate VPF, a mathematical model was constructed by composing parts of rotational bodies and a prism, subject to geometrical parameters of the proximal femur that were assessed from radiographs. The mean value of VPF in the group of cases was 113.9 (21.0) cm3 and significantly lower compared to 164.0 (38.4) cm3 in the control group (P < 0.01). Based on the preliminary results, the VPF seems crucial for the PPFFs prevention. The bone stock preservation should be emphasized and considered at all steps, starting from the preoperative planning. The novel parameter in THA, and the method for its evaluation were introduced and are further extensively analysed.

Background: Hip resurfacing arthroplasty (HRA) is commonly performed using the posterior approach (POS), which is familiar to most surgeons and allows excellent exposure. POS sacrifices the short external rotators and often the gluteus maximus, which may adversely affect gait. The anterior approach (ANT), which is muscle sparing has been shown to preserve more physiological gait patterns in total hip arthroplasty. Aims: We aim to compare the outcomes of POS and ANT using gait analysis and the Oxford Hip Score (OHS). Methods: Thirteen unilateral ANT and 20 POS HRAs were matched for age, BMI and pre-operative OHS. Patients underwent gait analysis using an instrumented treadmill at an average of 1.5 (0.9-1.8) years post-operatively. OHS were completed pre and postop. Kinematics and kinetics were recorded using motion capture and force plate data. Group differences were assessed using statistical parametric mapping. This data was compared to a group of 19 age, gender and BMI matched healthy controls. Results: Gait analysis revealed ANT group demonstrated significantly more hip adduction and less hip abduction compared to the POS from 25 to 57% (P = .003) of the gait cycle. Statistical parametric mapping revealed no differences in ground reaction forces across the stance phase. Both groups demonstrated similar top walking speeds. Average OHS for both groups postoperatively was 48. Conclusions: The ANT group exhibited differences in frontal kinematics compared to POS but both were within the range of healthy controls. ANT for HRA although technically challenging can produce excellent reported outcomes and restore normal gait patterns.

Background: Factors affecting direction of pelvic obliquity (PO) in dysplastic hip osteoarthritis (DHOA) remains unclear. This retrospective cohort study evaluates morphological characteristics, spinal alignment, and hip function in patients with unilateral DHOA. Methods: Between 2018 and 2022, 104 patients with unilateral DHA were enrolled. Patients were categorized based on preoperative pelvic obliquity into flat (PO < 2°) (F-PO group), affected side (PO downward by ≥2°) (A-PO group), and unaffected side (PO upward by ≥2°) (U-PO group). Demographics, radiographic hip and lower limb parameters, spinal parameters, and functional scores were compared between the groups. Results: There were 39, 44, and 21 patients in the F-PO, A-PO, and U-PO group, respectively. The subluxation percentage of Crowe classification showed a significant difference among the three groups. The femoral head lateralization distance was significantly greater in the U=PO group than in the F-PO and A-PO groups. Furthermore, the hip adduction angle was significantly lower in the A-PO group than in the F-PO and U-PO groups. The lumbar scoliosis angle was significantly different between the groups. In multivariate analysis, hip adduction angle was extracted as an independent factor associated with the affected side PO. Age, subluxation percentage, and hip adduction angle were identified as independent factors associated with the unaffected side PO. The Japanese Orthopaedic Association hip score was significantly poorer in U-PO group than in F-PO group. Conclusion: The results of this study revealed that the degree of hip contracture and subluxation due to osteoarthritis affect the direction of PO in DHOA.

INTRODUCTION: Total hip replacement in cases with acetabular defects are always challenging. The goal is to provide a rigid fixation of the acetabular cup and restoring the center of rotation of the hip, thus increasing the survivorship. METHODS: A total of 40 cases of acetabular defects have been included in our study. These include post acetabular fractures either treated conservatively or fixation, primary arthritis, post hemiarthroplasty causing protrusion or aseptic loosening in THR, and two cases due to lytic lesions in the acetabulum. All our cases were approached posteriorly. Once the acetabulum is exposed, the defect is quantified. Cases with contained defect, impaction grafting was done. Augmentation was done with either allografts or augments, in cases with posterior or superior uncontained defects and fixed with screws. In cases of medial wall defects, mesh with impaction grafting and cemented cup was used. In cases with pelvic discontinuity with massive bone loss, cup cage construct was done. Trial component with full inherent stability is achieved., which couldn’t be displaced by pushing on its rim or by trial reduction. Harris hip score was used for assessment and found to be comparable at one year follow up. Radiological evidence showed good integration of the grafts. DISCUSSION : In any method of augmentation., position of the acetabular cup must be ensured for stability of the acetabular component and restore the centre of rotation of the hip joint. These prevent migration, recurrent loosening and dislocation.

Introduction: In total hip arthroplasty (THA), cementless cup without screw holes has the putative benefits of maximizing host bone contact and reducing osteolysis by eliminating channels to backside wear particles. However, these theoretical benefits had not been proved previously. Materials and Methods: 74 hips in 60 patients receiving same model of cementless cup without screw holes from 1999 to 2003 were prospectively followed up. All patients were allowed to have immediate full weight bearing. Age at THA was 53 ± 13 years. Survivorship was assessed using revision of the cup as the end point. Radiological parameters, including lateral opening angle, vertical and horizontal migration distances of the cups were measured. Survival analysis is performed. Results: 51 hips were assessed at minimum 20 years follow-up. The mean follow-up was 22.6 (range 21 – 25) years. All the cups were well fixed. There were two cup revisions. Conventional polyethylene (PE) was used in both hips; Peripheral osteolysis occurred 17 and 18 years later. Both cups were well fixed but were revised, one due to cup mal-positioning, one due to need in upsizing the articulation. No cases having osteolysis at back of cups occurred. At 20 years, the survivorship of cups was 96.1%. Changes in lateral opening angle, vertical and horizontal migration distances were 0.44±1.59°, 0.01±1.52mm and -0.32±1.47mm respectively, without statistical significance. Conclusion: This study provided the first clinical evidence of cementless cup without screw holes achieving an excellent long-term survivorship. No cases developed central osteolysis due to its no screw holes design.

Introduction: One of the purposes for total hip arthroplasty, is to restore hip biomechanics to the patients. Offset is an important parameter to determine hip implant position. Robotic assisted total hip arthroplasty has an important role to improve precision in hip implant position. This study aimed to compare offset parameter of robotic assisted total hip arthroplasty and manual total hip arthroplasty cases.
Methods: A cross section observational retrospective review study was conducted. 51 patients who underwent cementless primary total hip arthroplasty during 2021-2022 at Siriraj Hospital with normal contralateral hip were involved in our study. We grouped the patients into manual and robotic assisted total hip arthroplasty cases then evaluated radiographic parameters and reported functional scores at postoperative 6 months.
Results: There were not significantly difference in all offsets different, leg length discrepancy, cup abduction angle, operative time, blood loss and Modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score Short Form and The EuroQol 5 Dimension 5 Level at postoperative 6 months between robotic total hip arthroplasty and manual total hip arthroplasty.
Conclusion: Robotic assisted THA was not difference to manual THA in means of acetabular offset different, femoral offset different, global offset different, leg length discrepancy, cup abduction angle, operative time, blood loss and all 3 reported functional score at postoperative 6 months.
Keywords: Offset restoration, Robotic total hip arthroplasty, Manual total hip arthroplasty

Appropriate stem offset is of utmost importance in total hip replacement, since it determines the hip forces, range of motion, leg length and implant survival. To preserve the natural hip geometry, preoperative planning is routinely performed. We are using five EcoFit (Implantcast) families of stems with various geometrical features, each family having 10 dimensions. We choose one of the stems with the aim to conserve as much bone stock as possible, i.e. we are planing for the medium head with resection of the neck 1-3 cm above the lesser trochanter, depending on individual situation. Greater volume of bone stock diminishes the incidence of periprosthetic fractures. With our reference mathematical model, we have calculated resultant hip joint force, abductor force, and contact joint pressures depending on the position of rotation center for various stems (offsets). The results are presented in nomograms. We find the five families of EcoFit stems suitable for optimal preoperative planning. Typical mistakes in total hip replacement, i.e. leg elongation and too short stem offset can be avoided. We advise preoperative planning on the contralateral side, since on the side of planned operation the hip tends to be in external rotation, which makes the stem offset falsely shorter. In bilateral cases 5-10 mm elongation should also be planned in order to compensate for the loss of articular cartilage and to restore the original length.