Background
Elderly patients with hip fractures can benefit from surgery, though optimal time to surgery is controversial. Some studies report reduced mortality from early surgery(<48 hours). The aim of this study was to determine if delay to surgery of more than 48 hours was associated with poorer functional outcomes and increased 1-year mortality rates for elderly hip fractures.

Methods
A retrospective review of elderly hip fracture patients in a single institution from January 2014 to December 2018 was conducted. Patients were divided into 2 groups depending on hours from admission to surgery: Group 1(<48 hours) and Group 2(>48 hours); these groups were matched for the initial Modified Barthel’s index(MBI) and Charlson comorbidity index(CCI). Functional outcomes via the MBI, ambulatory status, return to community and 1-year mortality rates were reviewed.

Results
2562 patients were eligible for the study. After 1:1 matching, there were 888 patients in each group. There was no significant difference in gender, age and fracture type between the groups. Group 1 had significantly better MBI scores at 6-months (mean 78.7 (SD 19.9) vs. mean 75.5 (SD 20.6)) and 1-year (mean 80.4 (SD 20.1) vs. mean 76.9 (SD 22.3))(p<0.001). There were significantly more patients in Group 1 who were community-ambulant (31% vs. 23%) and independent in ambulation (29% vs. 22%)(p<0.001). There was no significant difference in 1-year mortality (3.7% vs 4.4%).

Conclusion
Early intervention for elderly hip fractures within 48 hours conferred better functional outcomes at the 6- and 12-month mark. There was no significant difference in 1-year mortality.

Background:To investigate the feasibility and clinical efficacy of free vascularized iliac bone flap based on deep iliac circumflex vessels graft for the treatment of osteonecrosis of femoral head (ONFH). Methods:216 patients (292 hips) undergoing ONFH were included from 2016 to 2023. After debridement of the necrotic bones, the vascularized iliac bone flap was designed and harvested, in which the deep circumflex iliac vessels and the transverse branch (or ascending branch) of the lateral circumflex femoral artery and their accompanying veins were anastomosed. X-ray was obtained at 1, 3, 6, 9, and 12 months respectively for evaluation of the bone flap healing. Hip function was evaluated with Harris hip score (HHS) at 36 months postoperatively. Results:The majority of hips healed well; five complications arose: 17 patient (5.8%) developed superficial wound infection, 12 patient (4.19%) experienced hematoma, 18 patients (6.2%) developed heterotopic ossifications, and 24 patients (8.2%) suffered anterolateral femoral cutaneous nerve injury. X-ray films at 12 months showed improvement in 223 hips (76.4%), 56 hips (19.2%) were unchanged, and 13 femoral head collapse with conversion to total hip arthroplasty (4.5%). 126 cases followed up for more than 3 years, with an average HHS score of 84.2 ± 3.5 which was significantly improved compared to the preoperative results (P < 0.05). The hip preserving ratio was 95.7% at the 1-year follow-up and 93.3% at the 3-year follow-up. Conclusions:Free vascularized iliac bone flap based on deep circumflex iliac vessels graft is an optimal treatment option for ONFH in stages ARCO II and III.

Introduction: Modified Dunn osteotomy addresses all the deformities of slipped capital femoral epiphysis (SCFE), but has the potential to cause avascular necrosis and chondrolysis. Trochanteric osteotomies create a distal deformity to compensate for the proximal deformity. We describe a modified trochanteric triplane osteotomy (MTTO) with a 1300 ABP, without removal of bone wedge for moderate and severe SCFE. Methods: The study was done in patients, who underwent MTTO (minimum 2 years follow-up) for moderate/ severe chronic stable SCFE from July 2018 to December 2021. Radiological outcomes were assessed using alpha angle, neck shaft angle, mechanical axis deviation and limb length discrepancy (LLD) on scannogram. Functional outcomes were assessed using modified Harris hip score, lower extremity functional scale (LEFS) and SF-36 questionnaire. Results: A total of 11 patients and 13 hips were included. The mean age was 12.9±2.1 years. 12 had severe slip and 1 had moderate slip. All osteotomies united uneventfully. At 37 months follow up, the mean neck shaft angle was 1290 , mean alpha angle was 69.70, and mean LLD was 1.05cm. There was significant improvement in the post-operative modified Harris hip score (p<0.001), from 73 to 96 postoperatively, and the median LEFS was 78. 1 case had bone scan evidence of AVN, but did well with restricted weight bearing and bisphosphonate therapy. Conclusion: MTTO is a safe and effective option for chronic moderate and severe SCFE. However, a residual proximal femoral Cam deformity persists after this procedure which may need to be treated with an osteochondroplasty.

Aim: Despite favourable long-term outcomes of cemented stem fixation in hip arthroplasty, complications like bone cementation syndrome and rare cement intravasation pose risks. The incidence of bone cementation syndrome is well documented, however, data on cement intravasation is limited to case reports. Methods: In this single-centre retrospective study, we evaluated 1100 cemented hip arthroplasties from 2012 to 2023 to identify cement intravasation incidence and related postoperative complications. Detection involved analysis of surgical reports, radiographs, and CT scans, with outcomes including embolism and DVT. Results: In 1,100 hips, a 0.63 % incidence of cement intravasation was noted using AMI TM stems and high-viscosity cement. All cases employed a fourth-generation cementing technique. No postoperative complications like DVT or embolism were observed. Conclusion: The study documents the incidence of cement intravasation with cemented hip stems using high viscosity cement and fourth-generation cementing technique. No major postoperative complications were noted associated with cement intravasation.

Introduction: Neck of femur fractures are amongst the most common types of fragility fracture, often necessitating further histological analysis to exclude malignancy as a precipitating factor. Whilst the Royal College of Pathologists (2011) recommend a low clinical threshold for investigation, there is currently no UK consensus regarding the circumstances in which the femoral head (FH) should be extracted and sent to histology. In this study, we aimed to identify whether routine histological analysis of FH in patients with proximal femoral fractures is justifiable in certain patient populations. Methods: We performed a retrospective search using Clinical Portal and PAX, following extraction of relevant patient cohort from handwritten histology logbooks, as per local hospital audit guidelines. Our selection criteria specified FH specimen sent to histology between dates of March 2022 – March 2024; all legible phrase and spelling variations were accepted. Our primary outcome measure was the presence of positive histology following analysis of FH, including metastatic and/or new malignancy. Results: We identified 66 eligible patients with an average age of 82 ± 9.9 (55 – 101). The most common reason for histology was previous/concurrent medical history of malignancy (59.2%). Ultimately, only one histology specimen (1.5%) was positive for the presence of metastatic carcinoma, with no new malignancies discovered. Discussion: Previous/concurrent medical history of malignancy correlates poorly with positive histological analysis. Definitive national guidelines outlining circumstances in which FH histology should be conducted are required, as reliance on surgical judgement is not cost-effective in patient management nor clinical outcome.

Introduction: There is a common question amongst many joint arthroplasty surgeons as to how many doses of prophylactic antibiotics should one administer during primary hip and knee arthroplasty procedures. Some advocate for a single dose during the perioperative period whilst others want an extended antibiotic course. Methods: A systematic search was conducted across PubMed, Embase, and the Cochrane Library databases to identify relevant studies. The focus was on comparing the outcomes of single dose antibiotic prophylaxis against extended antibiotic prophylaxis in primary joint arthroplasty procedures of the hip and knee. The primary endpoints of this study were periprosthetic joint infection, revision surgery and superficial surgical site infections. A total of 744 studies were screened for title and abstracts. Of the 15 eligible studies two authors AF and JYP performed a blinded full text review and came to the unanimous conclusion of including 9 studies in this meta analysis. Results: Across 9 studies 295654 patients were included in this review of which 125489 were total knee arthroplasties and 172055 total hip arthroplasties. Conclusion: There was a significant statistical difference in terms of the incident of periprosthetic joint infection, favouring single dose antibiotic prophylaxis (Odd Ratio 0.78 [0.63, 0.98] 95% CI, Heterogeneity: Tau = 0.00; Chi7 = 4.45, df = 5 (P = 0.49); I² = 0%). In summary, a single dose prophylactic antibiotic regimen proves to be more effective in reducing the incidence of periprosthetic joint infections.

Background:
Patient blood management recommends using intravenous (IV) iron infusion to reduce inappropriate blood transfusion perioperatively for anaemic surgical patients. However, evidence regarding its use in patients with femoral fractures is limited. This systematic review aims to collate the current evidence regarding the use of IV iron in femoral fracture patients managed surgically.

Method:
MEDLINE, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and the WHO ICTRP databases were systematically searched for randomised controlled trials comparing the outcomes of perioperative IV iron infusion with placebo in adults requiring surgical management for femoral fractures. Risk ratios (RR) were calculated using the Mantel-Haenszel method for dichotomous outcomes, and mean difference (MD) was calculated for continuous outcomes.

Results:
Six RCTs with 1085 patients were included. There was no statistically significant difference in the proportion of patients receiving red cell transfusion (RR:0.89, 95%CI: 0.80; 1.00), number of red cell unit transfused (RR:0.87, 95%CI: 0.64; 1.19), length of hospital stay (MD=-0.08, 95%CI: -1.04; 0.87), mortality rates (RR=1.01, 95%CI: 0.73; 1.40), infection rates (RR=0.89, 95%CI: 0.68; 1.16), and haemoglobin levels at the time of discharge (MD=1.73, 95%CI: -0.89; 4.35). Results from individual studies showed no statistically significant differences in functional and quality of life outcomes.

Conclusion:
There is a moderate to low level of evidence showing no significant difference in the proportion of patients receiving red cell transfusion, length of hospital stay, mortality rates, infection rates, and short-term haemoglobin level in femoral fracture patients receiving IV iron perioperatively. Further studies must confirm its effect on patient-reported outcome measures.

Introduction: Preferred treatment of Neck femur fractures in young adults is osteosynthesis. There is no consensus regarding ideal implant, although DHS/ Inverted triangle configuration of CCS are most commonly used. We tried to evaluate the superiority of BDSF over DHS as it provides Biplane double support fixation. Material and methods: 45 patients of neck femur fracture (Age between 18-55 years) were treated with BDSF or Dynamic Hip Screw with derotation screw and were compared for union, functional outcome and intraoperative parameters:blood loss, duration of surgery and radiation exposure. Results: Mean age was 38.5 years (range 19 to 55 years) and mean follow up was 9.25 months in DHS and 9.75 months in BDSF group. Union was seen in 21 of 23 patients in DHS and 21 of 22 patients in BDSF group. Mean blood loss, duration of surgery and exposure in DHS and BDSF was significantly different which was 196.8 ml and 74.67 ml, 76 min and 88 min, and 17 and 27 shoots respectively. Mean harris hip score and union time in DHS and BDSF was 85.8 and 86.1(p value >0.05), and 14 and 15.2 weeks respectively. Conclusion: Functional outcomes of BDSF and DHS are comparable although greater blood loss is expected in surgery in DHS group, whereas BDSF has increased duration of surgery and radiation exposure as it is a newer technique and need to be expertised by a learning curve.

Introduction: Hip fractures treatment is a growing challenge worldwide. Among them, trochanteric fractures are mostly fixed, while femoral neck fractures (FNF) could be treated either with arthroplasty or with fixation.
Aim: The aim of this study was to compare radiological outcome of fixed FNF with fixed – angle gliding fixation device (FNS) with other techniques (OT) in Pauwels I and II vs. Pauwels III fracture type.
Methods: In period 2018. - 2022. we identified 1659 patients with hip fractures in our institution. 47% had FNF. We found 94 patients (12% of all FNF) where femoral neck fixation fixation was done. 39% of them were fixed by FNS, 61% by OT. We analyzed fracture type using Pauwels classification, implant positioning and fracture healing. X – Rays were analyzed by two surgeons and one radiologist.
Results: There was 60% Pauwels I and II fractures and 40% Pauwels III fractures. We found overall fracture healing after FNF fixation in 72% patients. Fracture healing at fixed Pauwels I and II fractures was in 84%, in Pauwels III fractures 53%.
There was 15 (44%) Pauwels III patients treated with OT and 19 patients (56%) treated with FNS. 11 OT fixations (73%) failed, 5 FNS fixations (26%) failed. We found suboptimal reduction on 5 failed OT fixation (45%) and on 4 FNS fixations (80%).
Conclusion: We found FNS is superior in treatment of Pauwels III femoral neck fracture fixation comparing to OT. Overall 67% of implant failure goes with suboptimal femoral neck fracture reduction.

Purpose: This study aimed to identify factors related to collapse progression in Japanese Investigation Committee classification type B osteonecrosis of the femoral head (ONFH) and to identify patients who would benefit from surgical treatment.
Methods: This study included 41 patients with type B ONFH with a minimum follow-up of 3 years. Based on a ≥3 mm collapse progression in ONFH, we categorized patients into two groups: collapse progression and no collapse progression. Sagittal and coronal computed tomography images were used to measure the necrotic region relative to the intact femoral head diameter. The ratios of the necrotic regions of transverse and vertical diameter in coronal and sagittal images are defined as the mediolateral transverse and mediolateral vertical, anteroposterior transverse and anteroposterior vertical, respectively. Demographic data and these imaging findings were compared between the two groups. We established a cut-off value for predicting collapse progression through receiver operating characteristic analysis and determined survival rates with collapse progression as the endpoint.
Results: Type B ONFH had a 17.8% collapse progression rate. The mediolateral transverse, mediolateral vertical, anteroposterior transverse and anteroposterior vertical were significantly higher in the collapse progression group. Mediolateral transverse was an independent risk factor of collapse progression (hazard ratio, 1.27; 95% confidence interval, 1.03–1.57; P = 0.03), with an mediolateral transverse cut-off of 45.6%. The 5-year survival rates with collapse progression as the endpoints were 57.0 and 94.9% in the ML transverse of ≥45.6 and <45.6%, respectively.
Conclusion: A mediolateral transverse of ≥45.6% predicts collapse progression in type B ONFH.

Introduction: The Direct Anterior Approach (DAA) for Total Hip Arthroplasty (THA) offers multiple benefits compared to other approaches. While DAA is routinely executed on both standard operative tables and specialized orthopaedic fracture tables, comparative studies on muscle damage associated with these tables for single surgeons are limited.

Methodology: This prospective cohort study involved patients aged 18-60 years with symptomatic hip arthritis, treated from February 2022 to March 2024. All procedures were performed by the same surgeon at a single institution. Muscle damage was evaluated using the modified Goutallier Classification System via MRI at 3 months post-operation. Patient outcomes were further assessed at 2, 6, and 12 weeks postoperatively using the Forgotten Joint Score for Hip (FJS-12) and the Harris Hip Score.

Results: The study divided patients into two groups: those operated on a standard operative table(group 1) and those on an orthopaedic fracture table(group 2), with 20 patients in each. The prevalent cause of hip arthritis was avascular necrosis followed by traumatic arthritis. Group 2 exhibited significantly lower muscle damage according to the Goutallier score (p<0.05), with reduced insult on the Ilio-psoas and Tensor fascia lata muscles.

Conclusion: Utilizing a fracture table for THA via DAA reduces muscle damage, and supports predictable surgical manipulation facilitating earlier rehabilitation and discharge. These findings highlight the fracture table's potential as a tool for leg manipulation to reduce muscle trauma during DAA THA.