BACKGROUND: In-hospital hip fractures follow falls during unrelated admissions. Little data in the Irish setting is available on this vulnerable subset of hip fracture patients.
OBJECTIVES: To review the incidence of in-hospital hip fractures, identify risk factors, and evaluate outcomes.
METHODS: We collected patient data in St James’ Hospital using the Hospital In-Patient Enquiry database, Electronic Patient Records, and phone calls, for in-hospital hip fractures between 10/02/2017 and 22/04/2020.
RESULTS: We identified 40 fractures, representing 11.5% of all hip fractures treated at our centre during the study period. Patients were 60 -95 years old. Median age was 77yo for males and 86yo for females.
Most (72.5%) were identified as falls risks, and 52% were unwitnessed falls.
Many had a history of falls (67.5%), dementia (52.5%), or both (42.5%).
Delirium was common (42.5%), and 75% had at least one vascular/coagulation disorder.
Average time to orthopaedic review was 0.7 days, and average time to surgery was 2.05 days.
Mortality was 10.25% at 30 days, 23.1% at 90 days, and 51.4% at 12 months.
Although 70% were admitted from home, only 10% were discharged back home. 30% were admitted from a nursing home and 55% were discharged to a nursing home.
CONCLUSIONS: In-hospital hip fractures accounted for 11.5% of all hip fractures treated at our centre, confirming the need for a well-defined hospital protocol. Patients often present with previous falls, dementia and cardiovascular disease. Outcomes are poor, with 51.4% mortality at 12 months and significant morbidity reflected by a loss of independent living.

Introduction:Hip dysplasia is a congenital morphological disruption of the hip joint,it is a major cause of secondary hip osteoarthritis in young subjects. The most common are acetabular dysplasias which present a problem with stripping,resulting in a smaller cartilage surface of the acetabulum to support the weight of the body,which will deteriorate.Conservative acetabular abutment treatment completes an insufficient roof with an oblique bone graft downward,outward and forward in order to increase the contact surface and decrease the unit pressure on the femoral head. Indicated in a young subject <40 years without radiological osteoarthritis or early osteoarthritis, without eccentricity, without subluxation, should not be high or low, and delay the maturity of arthroplasty. Material and method:Our series includes a retrospective study going between 2000 and 2013, of 16 patients (12 women and 4 men), with an average age of 31 years,and an average follow-up of 10 years, all our patients were treated by acetabular stopper including 11 embedded and 4 fixed by screws. Results:Functionally, there was a clear improvement in pain and lameness,with 90% of patients very satisfied,Merle d'Aubigné's rating went from fair (12-13) to good (15-16).noted one case of superficial sepsis and one case of thrombophlebitis without late complications.Discussion:Our results match those of the literature with few complications,and a clear satisfaction of our patients.The action of the acetabular stopper on pain and preservation of the hip has been reported by several authors.Conclusion:The acetabulum is a simple technique, easy to perform, giving encouraging functional results, and which delays the deadline for arthroplasty.

Purpose: This study prospectively reports survivorship and radiographic and clinical outcomes following primary elective total hip arthroplasty (THA) using a novel single hemispherical, porous-coated acetabular cup with five different bearing combinations and a minimum of five year follow-up.
Methods: Continuing post-market release monitoring of this cup, we prospectively enrolled 108 patients (121 THA) between 2009 and 2015. We followed this cohort by examining survivorship, in addition to clinical and radiological outcomes for metal-on-metal (MoM) compared with non-MoM bearing combinations (ceramic-on-ceramic, oxinium-on-polyethylene, ceramic-on-metal, and metal-on-polyethylene).
Results: All 108 (121 hips) patients were followed up. Average age at time of surgery was 45.1 years (range 19 to 71 years) of which 42.1% were males. A total of seven (5.8%) cups were revised, all of which were MoM. No osteolysis was observed in any of the patients at the latest visit with a mean follow-up of 9.1 ± 1.7 years (range 4.4-10.7 years). With MoM excluded, survivorship of the cup at five years is 97.8%. Survivorship for MoM implants was 90.0%. Validated hip scores showed significant improvements for all bearing types and no significant difference between groups at latest follow-up (p = 0.614). There was no cup migration with any bearing surface.
Conclusion: This cup showed excellent survivorship at five year follow-up, except for patients receiving a MoM articulation. While there were concerns over the early survivorship of this cup, our cohort and joint registry data confirm excellent outcomes.
Keywords: Acetabular component; Articulation; Hip arthroplasty; Modular; Survivorship.

Objectives: This study aims to develop a screening tool that will help paramedics identify patients with hip fractures on site and direct these patients to hospitals with orthopaedic surgery services.

Study Design: Prospective Survey

Methods: Literature and expert opinion defined parameters for the Collingwood Hip Fracture Rule (CHFR) which predict a patient’s likelihood of hip fracture. The study population included adults presenting to Collingwood General and Marine Hospital (CGMH) with lower extremity injuries between December 1st, 2019–March 10th, 2020. Excluded patients had previous hip replacement, hip fracture on the side of the injury, or a high energy mechanism of injury. Patients were assessed with the CHFR before receiving x-ray imaging. The parameters were scored based on their predictive powers and analysed by a Receiver Operating Characteristic (ROC) curve.

Results: The study included 101 patients (mean age 66.3 years), and 25.7% had a fracture confirmed on imaging. The sensitivity, specificity, positive predictive value, and negative predictive value helped score each parameter; Score=1: age 65-79 years, female, mechanical fall, unable to weight-bear, knee pain; Score=2: bruising at greater trochanter; Score=3: pain with hip rotation, leg shortened & externally rotated. Age >80 years (score=2) was derived from age analysis. The ROC curve (0.953; p-value <0.0001) demonstrated scores of 3 and 7 had sensitivity:specificity of 100%:34.7% and 84.6%:94.7%.

Conclusion: CHFR screening tool can be used by paramedics in the prehospital setting to identify patients who sustained a hip fracture and make appropriate triage decisions. This will improve patient outcomes and decrease institutional costs.

Background: Hip fractures remain a significant healthcare problem worldwide, with an annual incidence of 1.7 million. One-year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. The purpose of this study was to determine and correlate the outcomes in terms of (1) demographic and clinical profile, (2) operative time, (3) length of hospital stay, (3) Charlson Comorbidity Score (CCS) and (4) Morbidity, and Mortality. Methods: This 5-year retrospective correlational study involved a total of 92 patients who underwent hemi-arthroplasty in the treatment of acute femoral neck fractures in the elderly population. A comprehensive chart review and statistical analysis was done to determine significant relationships between variables. Results: The average age was 73.46 (SD=9.6). Majority of the subjects were female at 81.4%; and sustained the injury secondary to fall (91.3%), whereas, 8.7% were due to vehicular accidents. Patients who were treated with Austin-Moore prosthesis comprised 31.5%, 53.2% had a Thompson prosthesis, and 15.2% had a Modular Hip prosthesis. Participants were hospitalized for an average of 11.29 days (SD=5.51) and had an average CCS of 4.28 (SD=1.48). No significant difference was found between groups in terms of operative time, length of hospital stay, and ambulation status. Conclusion: Return of the patient to his/her pre-fracture functional status can be achieved with the treatment of hemiarthroplasty. This study showed that outcomes of hemiarthroplasty were comparable to other studies and is a satisfactory treatment modality indicated for treating elderly patients with femoral neck fractures.

Introduction: Short stem THR is becoming increasingly popular, but concerns exist about initial stability an possibly increased Proximal Femoral Fracture (PFF) rate.
Methods: We investigated the results of a new Titanium short stem THR, with emphasis on PFF and stem stability, and report the 1 to 4 year FU of a single surgeon consecutive series of 467 THR . All patients had a fast recovery programme and were allowed full weight bearing immediately.
Results: The most important complication was PFF (2,9%), which occurred always intra-operatively or within the first 3 weeks of surgery. In 453 THR where no PFF occurred, all stems were judged to be fully ingrown and functioning well upon review. No case of stem subsidence, progressive radiolucency, osteolysis or loosening was observed. There were no revisions for any reason, except for PFF. Females and patients older than 60 had a significantly higher incidence of PFF. There was a tendency for higher incidence of PFF in Dorr type A and smaller stems. There were no other risk factors for PFF.
Conclusion: The investigated short stem THR in this study shows a very good function and survival in the short term, but an unacceptably high peri-operative PFF-rate in the setting of a fast recovery programme in females and patients of higher age. Patients where this particular design is used, should be protected untill the stem is fully ingrown.

Introduction: Preoperative planning via identification and analysis of orthopedic implant design proves to be time and cost effective. The hospital transfers of patients and the generic nature of hospital records result in discrepancies which are not covered by current identification methodologies.
Focus: This study aims to advance on the detection system of orthopedic total hip arthroplasty implants using deep learning.
Methods and Analysis: Post-surgery lateral and anteroposterior X-ray images were collected from the patient records from Medical University of Tokyo and KMC Hospital. A collection of 927 images belonging to three classes were obtained. These images were augmented resulting in a total of 1921 images with 1762:159 train- validation split. After augmentation, these images were annotated by marking bounding boxes on the hip implants in the image. An additional query batch of 87 images was used for testing. The model used was YoloV5 which performed both detection of the implant in the image as well as informed the class of the implant. The set of 1921 augmented images along with their annotations were fed to the YoloV5 model for classification as well as detection. Inference on 149 test images resulted in 0.936 precision for YoloV5 on the validation set. A classification accuracy of ≥ 97 % was obtained on the test set.
Results: The recognition system for total hip arthroplasty using the YoloV5 model proved to be quite robust. The technology has been deployed in the form of a web application at https://hipimplantidentification.herokuapp.com/

Introduction: Studies into cost-related data pertaining to the value computer-assisted surgery is sparse. Relative value units (RVUs), used by the Centers for Medicaid and Medicare Services (CMS), have been utilized to assess the value of operative time. The purpose of this study was to compare operative and financial differences in traditional and computer-assisted (caTHA) THAs. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify patients from 2011 to 2016 who underwent caTHA and traditional THA via Current Procedural Terminology codes. Raw RVU values and conversion factors were taken from the CMS and American Medical Association websites. Univariate analysis compared operative time, length of stay, mean RVUs, reimbursement rate, and revenue. Results: 124,280 patients were identified, 122,401 and 1,879 underwent traditional THA and caTHA, respectively. Patients in the THA group had a longer LOS (2.7 vs. 2.2 days, p<0.001). caTHA had longer mean operative time than THA (99.1 vs. 92.5 minutes, p<0.001). The mean RVU per minute (0.26 vs. 0.25) and reimbursement rate ($9.27/min vs. $9.0/min) were higher for THA (both, p<0.001). Revenue per case ($889.53 vs. $857.17) and per day ($5,337.19/day vs. $5,143.03/day) were all significantly higher for caTHA than THA procedures (both, p<0.001). Conclusion: This study found that patients who underwent THA had shorter operative times but lengthier LOS than caTHA patients. Traditional THA procedures had higher reimbursement rates but generated lower revenue per case and per day than caTHA, an average difference in revenue of $31,065.60 per year.

BACKGROUND: The transition to outpatient enhanced postoperative recovery (ERAS) programs for total hip and knee arthroplasty (THA/TKA) is gaining momentum given the non-inferior to superior patient safety and clinical efficiency over standard inpatient care. However, evidence is lacking regarding the third pillar of quality of care: patient experience. This study aim was to obtain a comprehensive understanding of the patient experience by exploring the impacts of ERAS-outpatient compared to standard-inpatient. METHODS: A mixed-methods explanatory study was conducted on 48 patients who experienced both protocols contralaterally. Bivariate analyses were conducted between patient experience score and preoperative, postoperative and care components satisfaction. A reflexive thematic analysis was performed from survey data collection. RESULTS: Spearman correlations coefficient ranged from +/-[.002-.285] for preoperative and postoperative variables to +[.486-.661] for satisfaction of care components. The qualitative analysis identified one common theme across all phases of care: support makes the difference—for better and for worse. Four themes expressed patients enhanced experience with the ERAS-outpatient protocol: minimize inconvenience, home sweet home, returning to a functional state, ingredients for optimal wound healing. Patients suggested that better preoperative education and coherence of care between the medical and home care teams could further optimize their experience. CONCLUSION: Patient experience is fairly to moderately related to their satisfaction with components of THA/TKA care. It can be enhanced by implementing an ERAS-outpatient program that provides support throughout the care episode, minimizes postoperative discomfort, allows a quick return home and functional recovery, and uses wound management modalities that lead to better healing.

Background: Femoral head fractures are rare and frequently a consequence of hip dislocation after high energy trauma. Hip dislocation should always be reduced as soon as possible after all life-saving measures. CT scan is mandatory to evaluate articular congruency, intra-articular loose bodies, femoral head fracture pattern and associated injuries like acetabular fractures. Case Presentation: The authors present two cases of femoral head fractures treated surgically in our hospital center. Both presented with a posterior hip dislocation associated with a Pipkin II femoral head fracture. They were submitted to closed reduction of the hip and afterwards submitted to femoral head fracture osteosynthesis. We utilized the Ganz Surgical Hip Dislocation Approach with osteotomy of the greater trochanter to perform open reduction of the femoral head fracture and osteosynthesis with compression screws. This approach allows for an excellent visualization of the hip joint without disrupting the vascularization of the femoral head which is essential to prevent avascular femoral head necrosis in the future. Clinical Outcomes: Two years after surgery both patients are extremely satisfied with the results. They both present more than 100 degrees of hip flexion and no limitation in rotation. Their Harris Hip Score is 98 points and radiologically there is no sign of femoral head avascular necrosis. Discussion: The definitive treatment of femoral head fractures should be made by experienced hip surgeons and the Ganz Surgical Hip Dislocation Approach is an excellent approach to treat these injuries preventing the risk of femoral head avascular necrosis.

Introduction
The hydroxyapatite coating on the implant surface provides osteoconductive conditions that favour osseointegration of cementless joint arthroplasties. However, in a small proportion of cases, degradation, reabsorption and delamination of hydroxyapatite have been reported, which can become responsible for failure of total hip arthroplasty.

Goals
To present a case of loosening of the femoral component following primary total hip arthroplasty after loss of adherence between the bone and the metal-hydroxyapatite interface of the femoral component.

Material and methods:
71-year-old man with a total bilateral hip arthroplasty (2014/2016). After trauma (2020) the patient reported pain and functional limitation in the right hip. In the radiological control, a subsidence of the right femoral stem was observed and so it was decided to perform replacement surgery of the femoral component and revision of the acetabular component. During surgery, stem mobilization was observed, noting that the stem hydroxyapatite coating was completely separated from the metallic component, thus leaving the hydroxyapatite attached to the bone. The canal was reamed and a revision femoral stem was inserted.

Results
Six months after surgery, the patient presented with satisfactory clinical and radiological results. Intraoperative microbiological results were negative for infection and these results together with what was observed during surgery indicate that the failure of the arthroplasty was due to a failure in the hydroxyapatite coating.

Conclusions
Although new prosthesis veneering materials (hydroxyapatite) improve implant fixation, in exceptional cases veneering system failures can occur , loosening materials following trauma

A retrospective single surgeon cohort of 243 PAOs were performed on 220 patients between 2006 and 2020 across 2 hospital sites in England. There was a mean follow up of 63.8±3.9 months (8-169 months) and post-surgical complications were assessed throughout this period. Peri-operative blood results were available for 225 hips. There was a female predominance of 74.4% within the cohort and 56.6% of PAOs were performed on the right side, with 68.7% being undertaken via a minimally invasive approach. The majority of patients had a primary diagnosis of developmental dysplasia of the hip (68.6%) followed by Perthe’s disease (9.5%), with a mean age of 26.4±1.5 years (9-55 years) at the time of surgery. The most commonly occurring complications were superior pubic ramus non-union (9.1%), pain (7.4%) and inferior pubic ramus stress fracture (6.6%). 5 hips experienced posterior column non-union and 3 had posterior column stress fracture with 2 requiring plating. 14 required iliopsoas injection (5.8%), two needing iliopsoas exploration. 4.9% had lateral femoral cutaneous nerve symptoms and there was one incidence of sciatic nerve palsy in a revision PAO. 5 patients had acetabular migration, two of whom required revision. There was a mean peri-operative decrease in blood haemoglobin concentrations of 3.8±0.4g/dL for the 225 available, and 9 patients (3.7%) required a post-operative blood transfusion. No complications above grade III were recorded. The results are similar to that reported in the literature and show that PAO is a complex and effective treatment for acetabular dysplasia, with significant complications.

Introduction: In 2019, research showed that in the six acute adult Dublin hospitals, 1 in 11 patients with fragility hip fracture sustained a second contralateral hip fracture. These have implications of additional patient morbidity and cost to the Health Service. Relationship of the contralateral femoral neck-shaft angle and timing to the second hip fracture have not been established previously. Methods: A single hospital, retrospective study from 2013 to 2019 was undertaken to assess the contralateral neck-shaft angle (NSA) to predict the time to second hip fracture. NSA of 94 patients with second hip fracture were measured from pelvic radiographs and time to second fracture were analysed. Measurements were taken by two members of the research team, using a standardised measurement technique. Results: NSA ranges from 113.0 to 146.5 degrees, with an average of 130.2 degrees. Average time to second hip fracture was 3.5 years, ranging from 0.08 year (29 days) to 20 years (7326 days). 56% of second hip fractures occurred within 3 years of index fracture. No significant correlation was found between NSA and timing of second hip fracture. Discussion: We concluded that femoral NSA independently is not statistically significant in predicting the time in those patients that sustained a second hip fracture. Causes of secondary hip fracture are multifactorial and multidisciplinary fracture liaison services are essential to reduce the number of fragility fractures.

Introduction: Fracture neck of femur (NOF)is one of the most common fragility fractures of the lower limb. There is a variation in clinical practice between surgeons in selecting patients appropriate for THA. National Institute for Clinical Excellence(NICE) has issued guidelines to standardize practice and improve functional outcomes in patients who are physiologically fit and have a high level of physical activity. Objectives: To review adherence to NICE guidelines when operating patients with intracapsular NOF fracture in our trust and to evaluate postoperative functional outcomes in these patients. Methodology:A retrospective review of the prospective NHFD data from 1st January 2018 to 31st August 2020. All patients who sustained an intracapsular NOF fracture were identified. Data collection included demographics, surgery, approach, type of implant, postoperative functional outcome, assessing compliance to NICE guidelines, that is, pre-injury mobility, ASA grade and cognitive function. Results: Over 3 years, NOF was diagnosed in 902 patients, intracapsular NOF were 389. Of these, 77 patients were operated with THA. The mean age was 73.52 years (60-91), 77% patients were female. Six patients who were not eligible were operated for THA. Overall, 92.2% of patients correctly underwent THA in line with national guidelines. Four patients had complications postoperatively, 2 each had infection and dislocation. Conclusion: NOF fracture has a significant impact on the geriatric population. Early surgery is recommended to improve return to baseline mobility. Dementia and pre-morbid conditions are significant risk factor to postoperative functional outcomes. THA, when done after careful selection of patients has better functional outcome.

Large-diameter femoral heads (≥36 mm) were introduced to
decrease instability and improve the range of motion of the hip. We hypothesized regarding the clinical outcome and complications following THR in Indian population.
Methodology
A total of 70 patients with hip pathology were operated from November 2011 to July 2013by a senior surgeon for THR using the anterolateral approach. The Harris Hip Scores were recorded pre and postoperatively in all patients. Postoperatively, radiographs
were taken to check for evidence of implant loosening or osteolysis. The patients were followed up till a mean follow-up of 86.52 month.
Results
Of the 59 hips, majority (76%) had acetabular inclination of 46-55 degrees. Ninety percent of the stems were
in the central position and 10% were in the varus position. The average preoperative Harris Hip Score was
38.8 ± 5.7 (range: 24-46), which increased to 90.4 ± 7.3 (range: 78-94) at the last follow-up. A total of six
patients died (four died of MI and two of CVA) and two patients had infection which was treated with
antibiotics. Three cases of dislocation were observed; one following a fall one year after surgery and revision
total hip arthroplasty was done and two cases while getting up from the bed which were managed with
closed reduction and abduction brace for six weeks. Two cases of periprosthetic fracture were
observed which were managed with plating.
Conclusion
Lower dislocation rate and better range of movement reinforces the advantage of large-diameter femoral
head during THR in the Indian population.

Introduction: Periprostatic fracture treatment is a rising global issue that often leads to dilemmas and dubious solutions despite the proliferic algorithms. Our goal is to demonstrate the necessity of sound knowledge, precise surgical technique and excellent command of the surgical technique relevant to each implant. Method: All patients in our institution ( 21 of which 17 male and 4 female patients), operated with a cable plate osteosynthesis between May 2016 and May 2021. Evaluation of fracture type, time to surgery, operative timing, time to full weight bearing, time to radiological consolidation, need for blood transfusion, VAS and Cochrane scale assesment. Results: all 22 patients have restored their independent mobility even if reduced at seven cases. Reduced by the surgery time was observed that could be explained with the completion of the performing surgeons learning curve. All but three patients never needed blood transfusion which confirms the importance of the surgical technique. VAS scores were improved to 2 in 20 patients in two months time after the operation. Four times revision osteosynthesis was necessary because of proximal cable malpositioning Conclusion: The cable enabled plates used for the periprosthetic fracture of the femur are offering many advantages but are still difficult to place and to secure properly. Meticulous technique is a must as well as scrupulous hemostasis. The learning curve is not as steep as one usually expects.

In the structure of complications, residual pain syndrome, which is not associated with infection or instability of the components of the hip arthroplasty, remains a serious problem due to difficulties in diagnosis and treatment. The cause of residual pain may be the presence in patients of concomitant diseases of the lumbar spine, which is embedded in the term "hip-spine syndrome" (HSS). The authors analyzed the clinical, radiological and instrumental data of 138 patients with HSS who underwent total hip arthroplasty. It was determined that the residual pain syndrome after surgery was determined in 32 patients, which amounted to 23.1% of the total number of patients with HSS. Of these, 6 cases (4.3%) were patients with discogenic radiculopathy, 6 cases (4.3%) - patients with spondylolisthesis and 20 cases (14.5%) - patients with pathology of the sacroiliac joint. All patients with residual pain after consultation with related specialists (neurologist, etc.) were prescribed a comprehensive conservative treatment, which included the use of nonsteroidal anti-inflammatory drugs, anti-edema therapy, blockade, massage, physiotherapy). The use of the above treatment measures reduced pain to satisfactory performance (according to the VAS scale) in 28 patients with HSS (87.5%). In 4 people with discogenic radiculopathies (2 patients) and spondylolisthesis (2 patients) 6 months after arthroplasty due to ineffectiveness of conservative treatment, spine surgery was performed (discectomy and transpedicular fixation L3-L4, respectively). After surgery, the intensity of pain decreased to satisfactory levels.

Introduction: Patients with a Pauwel type III displaced intracapsular femoral fracture (DICFF) have high risk of developing avascular necrosis (AVN) and non-union following closed reduction and internal fixation. It is unclear whether the method of fixation between the cannulated cancellous screws (CCS) and the Targon femoral neck (TFN) plate affects the risk of failure following fixation in these patients. The purpose of this study was to compare the complications between the TFN method and the CCS in patients with Pauwel type III fractures. Methods: We retrospectively reviewed patients under the age of 65 with Pauwel type III DICFF who underwent closed reduction and internal fixation in our center from January 2007 to January 2018. Extracted data included baseline characteristics and the fixation method. Postoperative radiographs were obtained during follow up visits to evaluate for complications such as AVN and nonunion. Results: 34 patients were included in the study, 18 were treated using TFN, compared to 16 who were treated using CCS. Between the CCS and TFN cohorts, there was no significant difference in the age (p =0.90), gender (p = 0.27), time to surgery (p = 0.36) and the length of surgery (p = 0.99). The rate of failure (AVN and non-union) between the TFN and CCS groups did not significantly differ (38.9% and 43.8%, respectively, p = 0.083).
Conclusions: The method of fixation between CCS and TFN had no significant effect on the failure rate in patients with Pauwel type III fractures treated by closed reduction and internal fixation.

Introduction: There has been a rapid increment in the usage of navigation system in enhancing the success rate in total hip arthroplasty (THA) over the conventional approach. This meta-analysis aimed to compile all the randomized controlled trials (RCTs) available comparing all forms of navigation techniques and conventional approach in THA.
Method: Databases of PUBMED, EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until February 2021. All RCTs comparing navigation and non-navigation approach in the THA were included.
Results: Twenty-eight RCTs, comprising of 2218 patients (Navigation: 1091, Non-Navigation: 1127) were included for quantitative analysis. The navigation approach was associated with higher number of hips within the Lewinneks Safe Zone (OR: 5.74, p<0.00001), longer operative time (MD: 11.50, p<0.00001), shorter leg length discrepancy (MD: -0.20, p=0.01) and better postoperative range of motion (MD: 1.00, p=0.004). No significant difference was reported in hip anteversion angle (MD: -1.11, p=0.27), hip inclination angle (MD: -0.51, p=0.45), postoperative Total Harris Hip Score (MD: 0.19, p=0.87), postoperative dislocation rate (OR: 1.06, p=0.95) and postoperative total complication rate (MD: 0.65, p=0.27). The meta-regression showed similar results between robotic assisted technique and non-robotic assisted technique in operative time (p<0.00001 VS p<0.00001), postoperative leg length discrepancy (p=0.07 VS p=0.07), postoperative Total Harris Hip Score (p=0.30 VS p=0.07), postoperative dislocation (p=0.78 VS p=0.49) and complication (p=0.16 VS p=0.99).
Conclusion: In this meta-analysis, navigation approach is more effective in achieving better clinical outcomes compared to conventional approach. However, future adequately powered RCTs are warranted to generate standardized outcomes.

Introduction: We wish to share the reflective learning on the management of an adult 47 year old male patient who presented with pain and stiffness left hip.He has with retained two holed DHS side plate and lag screw in his left hip from previous injury. Methods: The options of conservative and surgical interventions were discussed with the patient and was offered a staged reconstruction. Results: The patient underwent partial extraction of implants from the left hip which included removal of a derotation screw and two cortical screws from the side plate. Unfortunately 2 days later the patient developed a peri-implant fracture of the proximal femur. He then underwent extraction of two holed side plate and as the previous lag screw had osseous bonding it was left in situ. A long DHS side plate was used to refix the fracture. He developed postoperative wound infection for which he underwent multiple wound washouts and delayed closure. He grew staphylococcus and enterococcus for which he received appropriate antibiotics for three months based on the culture sensitivities. Conclusion: At the time of recent follow up the wound healed completely well and the proximal femoral fracture showed signs of osseous healing. Reflection: A single stage reconstruction could be planned where the hip could be dislocated, neck osteotomized and metal cutting disc could be used to cut the lag screw if needed. The second option was to re-insert the screws in the two holed DHS plate which could have avoided the peri-implant fracture postoperatively.

Background
The major advantage of using an accelerometer-based navigation device is that does not require the intramedullary violation of the femoral canal and provides better alignment. The aim of the study is to compare the effect of using an accelerometer-based navigation device in total knee arthroplasty on perioperative parameters like operative time, blood loss, transfusion rate, length and complications during the hospital stay, and early functional outcome when compared to conventional total knee arthroplasty.
Methods
This study is a prospective, assessor-blinded comparative study of 70 patients who were randomly allotted using computer software two groups navigation group and conventional group based on instrumentation used for TKA. Perioperative parameters mentioned above and Knee society score at 6 weeks were recorded for every patient in either group and compared using appropriate statistical methods using SPSS software.
Results
Total blood loss which includes both intraoperative blood loss and drain volume was significantly higher in conventional group1146±312ml when compared to 967±418 ml in the navigation group(p<0.01). Moreover, the mean Hb drop, transfusion rate was also significantly higher in the conventional group(p<0.01). Though operative time was significantly higher, duration hospital stay was significantly lesser in the navigation group. There was no difference in postoperative complications or the KSS at 6 weeks between either group.
Conclusions
The use Accelerometer-based navigation system decreases the perioperative blood loss, need for transfusion, and duration of hospital stay with similar functional outcomes at 6 weeks when compared to conventional TKA.
Level of Evidence: Level 1, Randomized controlled study

Introduction: The aim of this study was to evaluate the rates of implant related complications in patients treated for trochanteric fractures using two types of implants (Gamma 3 and PFNA) and the link between complications and technical parameters of insertion. Methods: The patients were selected retrospectively between December 2020 and September 2018 by the inclusion criteria. Results: We analyzed 665 patients and we selected 300 by the inclusion criteria. The median age of the patients was 81 years (IQR:12), the female median age was 82 years (IQR:10) and male median age 78 years (IQR:14). 95% of patients were treated using a Gamma 3 nail and only 5% of them were treated using a PFNA implant. 60% of the patients presented a A1.3 fracture type following AO classification and 29% presented a A1.2 fracture type. The global complication incidence was 12.33%and the specific incidence found in this group was as follows: 3.67% cut-out, 7.67% lateral protrusion of the lag screw, 0.67% impossibility of distal locking and 0.33% the migration of distal locking screw. We found a statistical difference in postoperative neck-shaft angle between the two groups of patients treated with the two types of implants. Conclusion: Gamma 3 nail used for treatment of trochanteric fractures obtain a reduction closer to the physiological neck-shaft angle compared with PFNA implant. The most frequent complication in our group was lateral protrusion of the lag screw followed by cut-out.

We identified theatre door opening to fetch implants – sizes decided intra-operatively - as an area where improvement could be made in reducing human traffic into and out of theatre, reducing one risk factor for infection. Pre-operative planning by x-ray templating and placing a likely range of implants inside theatre prior to opening sterile instruments was a way of achieving this. An observer recorded when and why theatre doors opened during hip hemiarthroplasty from opening of sterile instruments to final dressing of the wound. Type 1 (Senior Author Practice): ‘Huddle’ reminders about door opening, pre-operative templating, likely range of implants ‘pre-loaded’ in theatre. Type 2 (Others): None of this, implants fetched from storeroom. Ten cases of each type were observed. Modular cemented hip hemiarthroplasty system; variable sizes of cement restrictor, stem plus centraliser, head, collar for varying length and offset. Results: Type 1 Breach average 5, range 0 - 6). Type 2 breach average 38, range 25 - 65. Most breaches involved anaesthetic/support staff, some not categorisable. Huddle reminders, templating, pre-loading likely implant sizes in theatre all reduce theatre door breaches and theatre human traffic considerably. Templating was accurate to within one size, but it can be impossible due to poor patient cooperation with imaging, previous surgery on opposite side. Modular system implants fetched individually during surgery can represent 10 episodes of avoidable door opening while sterile instruments are exposed and the wound open. The Type 1 approach is recommended for reducing unnecessary theatre door breaches and human theatre traffic.

Currently, we are poor at predicting the onset and preventing progression of hip osteoarthritis (OA). A theory by Murray suggested that the majority of OA cases is caused by subtle abnormalities of the hip joint. Aim: to determine the frequency and characteristics of hip joint anatomical abnormalities, that could be associated with OA development. Methods: 150 Pelvic radiographs of hip OA patients and 120 patients with a non-OA underlying disease or injury admitted to the Hospital of Traumatology and Orthopaedics were retrospectively examined and dividend into 2 groups. Methods: alpha angle, acetabular depth, acetabular index, pistol grip deformity, crossover sign was measured and assessed using the Impax-Orthopaedic-Tools 3.0.2.3 program. A statistical shape model was build using the BoneFinder 1.3.4 program which detects and sets 75 landmark points on the proximal femur and hemipelvis in AP pelvic radiographs. Results: Comparing predefined radiographic parameters, increased alpha angle (>50o) (p<0.001), Pistol grip deformity (p<0.001) (characteristic for Cam deformity), centre-edge-angle < 25o (p<0.001), acetabular index >47o (p=0.012) (characteristic for acetabular dysplasia), acetabular protrusion (p=0.02) (characteristic for Pincer-type impingement) was significantly more prevalent in the Arthritic group. The overall variation of the hip joint was divided into 10 modes. Patients with hip osteoarthritis had significantly higher scores of shape modes 1, 2, 4 and 6 (p=0.002; p=0.01; p=0.02; p=0.03). Conclusions: Hip joint characteristics defined by SSM as deformed head–neck junction, prominent acetabular posterior wall, larger femoral head, larger lesser trochanter, Cam- type impingement, hip dysplasia play a role in the development of OA.

Periprosthetic joint infection (PJI) can have devastating consequences. Of the various treatment options, debridement, antibiotics and implant retention (DAIR) is a less invasive surgical option. Still, it is only recommended to be performed within three months of the index surgery and three weeks of symptoms. A retrospective audit was conducted with a cohort of fourteen patients to firstly determine the compliance with these recommendations and secondly whether there was any significant difference in practice between those with successful DAIR procedures and those with failures. The overall success rate was 35.7%, and there was no statistically significant differences between the success and the failure cohorts, including time from index surgery and length of symptoms. The cohort of patients who had a DAIR of a hip hemiarthroplasty had 100% success rate, however there were only two in this group. A further study across multiple centers and with a larger cohort number is needed to determine whether these findings are consistent with general Orthopaedic practice.

Introduction
A higher prevalence of cam morphology has been reported in the athletic population but the development of the cam morphology is not fully understood. The purpose of this systematic review is to establish the timing of development of the cam morphology in athletes, the proximal femoral morphologies associated with its development, and other associated factors.

Materials and Methods
Embase, MEDLINE and the Cochrane Library were searched for articles related to development of the cam morphology, and PRISMA guidelines were followed. Data was pooled using random effects meta-analysis. Study quality was assessed using the Downs and Black criteria and evidence quality using the GRADE framework.

Results
The search identified 16 articles involving 2,028 participants. In males, alpha angle was higher in athletes with closed physes than open physes (SMD 0.71; 95% CI 0.23, 1.19). Prevalence of cam morphology was associated with age during adolescence when measured per hip (β 0 053), There was a paucity of data regarding the development of cam morphology in females.

Conclusions/Discussion
Very low and low quality evidence suggests that in the majority of adolescent male athletes’ osseous cam morphology developed during skeletal immaturity, and that prevalence increases with age. Very low quality evidence suggests that osseous cam morphology development was
related to lateral extension of the proximal femoral epiphysis.

Arterial injury in closed femoral fractures secondary to blunt trauma is a rare complication. A 60- year-old male care home resident with learning difficulties and poor mobility presented following a fall from his bed. Initial examination revealed an isolated, closed injury of the left hip with normal vascular and neurological findings. Radiographs confirmed a left comminuted subtrochanteric proximal femoral fracture with a displaced medial fragment. Patient did not tolerate skin traction and was most comfortable holding his hip in a flexed position. He was taken to the operating theatre for intramedullary femoral nailing. Once anaesthetised, he was transferred to the traction table and limb straightened. This resulted in sudden and significant hypotension, increasing swelling in his thigh and faint distal pulses in the left leg. Major haemorrhage protocol was activated, and he was resuscitated. Urgent vascular opinion was sought, and a CT angiogram revealed injury to the branches of the profunda femoris likely due to the displaced medial fragment of the proximal femoral fracture. He was taken for embolization and stabilised overnight prior to having definitive fixation with an intramedullary nail the following day. This case emphasises the importance of clear and frequent documentation of the neurovascular status of the limb following a proximal femoral fracture. It also highlights having a high suspicion for vascular injury following a proximal femoral fracture and low threshold for further investigation in the form of an ultrasound doppler or CT angiogram to allow for early intervention and prevention of a fatal outcome.

INTRODUCTION: Proximal femur fractures are associated with high morbidity and mortality, and loss of function in post-operative complications. An aging society contributes to higher numbers of injuries, where we want to use surgery for a form of treatment to return to former function. There are plenty of available implants, that are widely used and more popular than the increasingly less favorable dynamic hip screw.
METHODS: We searched the medical database Pub Med for articles that review the benefits and constrains of treating methods for proximal femur fractures. We also did a cost analysis of different implants.
RESULTS: In stable fractures, except in the elderly, there are no preferences for a chosen implant. In the older population, with unstable fractures it is preferred to use intramedullary nailing. Materials costs are lower in a dynamic hip screw.
CONCLUSIONS: PFN shows a better treatment outcome in unstable fractures. A dynamic hip screw has the benefit of being a cheaper option.
KEY WORDS: PROXIMAL FEMUR FRACTURES, SURGERY, COMPLICATIONS, MATERIAL COSTS

The search for a more durable hip prosthesis has led to the use of a metal-on-metal tribology, which achieves increased stability and lower wear rates. However, release of metal ions due to tribocorrosion, the so-called trunnionosis, can provoke a local inflammatory reaction in the form of a solid or cystic mass called pseudotumor. This lesion is neither neoplastic nor infectious, but can cause hip pain and osteolysis, which may lead to an incorrect diagnosis. We present the case of an 85-year-old male with history of advanced heart and lung disease, who complained of acute on chronic right-sided hip pain. The patient had undergone small diameter uncemented total metal-on-metal arthroplasty in the right hip and total metal-on-polyethylene arthroplasty in the left hip sixteen years and five years before, respectively. Despite surgery, low-grade bilateral hip pain persisted over the years but no signs of loosening or instability were evident. In this case however, an anteroposterior radiography revealed frank osteolysis of the right proximal femur and acetabulum and a computed tomography showed a large mass in the perithrocantheric region. Despite the absence of fever, inflammatory biomarkers were high and periprosthetic infection was presumed. The patient underwent removal of the prosthesis and excision of the tumor. Intraoperatively, the components were well fixed and tissue samples were collected. All cultures were negative and histopathological analysis revealed an inflammatory pseudotumor. The wound healed uneventfully and the patient was recovering well at three months post-operatively. A few days later, the patient died due to an unrelated cause.

Introduction: We noted the patients admitted with hip fractures to Salisbury District Hospital in 2019 did not meet the best practice tariff (BPT) well compared to the previous years and introduced changes to the clinical practice to improve the same. These changes improved the patient care, outcomes and achieved best practice tariff for patients with hip fractures. Methods: We reviewed the National Hip Fracture Database results for our hospital in the year 2019 (n= 309) and noted that only 79.9% patients with hip fractures admitted that year met the BPT. We stood in a 23rd position among 175 NHS Trusts in the United Kingdom and second in the southwest region. We implemented service improvement changes in the department to provide better care for these patients such as recruiting more medical staff, creating additional theatre capacity on days ( Wednesday and Thursdays) where BPT tariff was not met , ensuring better availability of physiotherapy services. We evaluated our performance in the next year (2020) and critically analysed the NHFD data from Salisbury District Hospital. Results: The NHFD data from the year 2020 showed that we achieved BPT in 82.7% cases(n=280) , stood seventh position nationally(n=171 Trusts) and first in the southwest region(n=16 Trusts). The inpatient stay for these patients reduced to 15.7 days compared 16.9 days in the previous year. Conclusion: We noted improved care for patients with hip fractures and improved compliance in achieving the BPT leading to financial gain for the Trusts and a reduced length of inpatient stay.

Traumatic dislocation of the hip is an extremely severe injury. Although previously considered an uncommon lesion, it is now seen more often as a result of motor vehicle accidents with high energy trauma, usually associated with fractures of the acetabulum which ultimately can result in a higher incidence of complications than in pure simple dislocations. This is a case report of a 26-years-old male, from an African country, policeman, with no relevant personal background history, that suffered a motorcycle accident with a posterior acetabular wall and tibial shaft fractures of the left lower limb in April 2018, both treated non surgically in his home country. He was admitted in our Hospital in May 2019, with chronic left hip pain, intolerance to weight bearing in the left lower limb, dependence of axillar crutches for walking and left lower limb shortening. In radiographic studies it was shown a tibial shaft with vicious consolidation, an acetabulum pseudarthrosis and was suspicious for hip dislocation. In CT-scan of the hip was found a posterior hip dislocation with chronic features such as signs of femoral head necrosis and the formation of a posterior neoacetabulum which precluded closed reduction to the native acetabulum. In November 2019 he was submitted to an uncemented total hip replacement (dual-mobility arthroplasty). The functional outcome after 1-year of follow up was very good with an increase of Oxford Hip Score from 8 to 41.

Introduction: Proper implant positioning determines good long-term outcomes in THA. Pelvis position change after patient positioning was suggested as a cause of cup misplacement. This experiment aims at explaining how unattended lateral pelvic tilt) will affect the cup inclination angle during THA. Methods: Using a pelvis saw bone model fixed to operative table, both ASIS were marked to put the pelvis squared to the table (a line connecting ASIS is parallel to a rod fixed perpendicular to the table). A cementless cup attached to a handle is placed at 45° angle measured in relation to the rod fixed to the table. Then the pelvis was tilted 5° toward the head and then toward the foot of the table, and the cup was again placed in an angle of 45° in relation to the rod and the angle between the cup handle and the line connecting ASIS was measured for both positions. All measurements were done using a protractor and a spirit level application of a smartphone. Results: When the pelvis was in a neutral position the cup was placed in the desired position (45°) when the pelvis was tilted to the head of the table, the cup was positioned in less inclination (40°) and when the pelvis was tilted to the foot of the table the cup inclination increased (50°). Conclusions: In this experiment, we simply proved the profound effect of unattended pelvic lateral tilt during THA after patient positioning and draping on the cup inclination angle.

Introduction: In the context of such a disabling traumatic event as hip fracture, it is important to evaluate the most important factors with predictive value for life expectancy. Comprehensive geriatric assessment (CGA) remains the most feasible tool in approximating the short-term prognosis in these patients. Material: We present a prospective study performed on a group of 64 senior patients hospitalized for hip fracture in our department, between December 2019-March 2020. We performed CGA pre- and 48-hour post surgery, and one-year survival was assessed. Results: One-year survival presented an estimated risk of more than 7 times higher in the age group over 78 years (RR=7.73; 95% CI: 1.03-58.02; p=0.009). In deceased patients, frailty recorded significantly higher mean scores both pre- (8.44 vs 4.62; p=0.001) and postoperative (10.0 vs 6.92; p=0.007). All deceased patients and 58% of survivors, had frailty (p=0.003) before surgery. The share of frailty increased in 84% of survivors (p=0.091) postoperative. Cognitive and emotional impairment were moderate-severe preoperative, without significant changes postoperative. Conclusions: CGA is a valuable tool in evaluating frailty in senior patients with hip fracture. Frailty remains an important prognostic factor of mortality and requires prompt identification and treatment.

Background: The effect of surgeon experience on accuracy of digital pre-operative planning for total hip arthroplasty (THA) remains unclear. The aims of our study were to compare pre-operative planning accuracy between fellow-trained orthopaedic surgeons and residents and to explore whether surgery indication effects the prediction accuracy. Methods: We prospectively reviewed 101 patients who underwent pre-operative digital templating for THA in our center from January 2019 to January 2020 with King Mark device. Extracted data included baseline characteristics and indication for primary arthroplasty. Pre-operative digital templating was performed separately by both a fellow-trained surgeon and a resident. Accuracy of each group was compared with the implanted components. Results: The overall adequate pre-operative planning of the acetabular cup (exact or + −1 size match) by the fellow trained group was higher compared with the resident’s group (77.2 and 64.3% respectively, p = 0.037), whereas the overall adequate preoperative planning of the femoral stem (exact or +/−1 size match) was higher in the resident’s group compared with the fellow-trained group (83.2 and 61.4% respectively, p < =0.001). The fellow-trained group showed better pre-operative planning of complex cases (developmental dysplasia of the hip and avascular necrosis of femoral head) than the resident’s group. Conclusions: The experience of the planner does not significantly affect the accuracy of correctly predicting component sizes. However, in complex cases, fellow-trained surgeons should assist residents in digital pre-operative templating for THA.

The goal of this study was to translate the Harris Hip (HHS) questionnaire into the Arabic language with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of total hip arthroplasty outcome. This questionnaire was translated following A clear and user-friendly guideline protocol. The Cronbach’s alpha was used to assess the reliability and internal consistency of the items of HHS. Additionally, The constructive validity of HHS was evaluated against the 36-Item Short Form Survey (SF 36). A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. Cronbach’s alpha of the total score of Arabic HHS is 0.528 and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Lastly, The correlation between HHS and SF 36 was r=0.71 (p<0.001) which represents a strong correlation between Arabic HHS and SF-36. Based on the results, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and total hip arthroplasty treatment efficacy.

Introduction: Total hip arthroplasty is the second most performed procedure in orthopedic surgery. The current orientation of surgery tends towards the least invasive procedures possible. The anterior approach by its inter-muscular and inter-nervous anatomical character allows faster functional recovery. As requiring a specific table and instrumentation, some surgeons are still resistant to it. So does it give satisfactory results without specific equipment? Methods: This is a prospective study on patients under 80 years with hip osteoarthritis or fracture of the femoral neck treated with total hip prosthesis through an anterior approach on an ordinary table and with an standard ancillary device. We studied the criteria of operating time, postoperative bleeding, inequality in length of the lower limbs and positioning of prosthetic implants, the fuctional evaluation at 03 weeks, 03 months and 06 months was assessed by the scores of Postel M, Harris and the Oxford-12. Results: We included 30 patients with a mean follow-up of 08 months, this was in 50% of primary osteoarthritis. Uncemented total hip prostheses were the most used 83.3%. Weight bearing was on first postoperative day for 100% of patients. We had to describe one fracture of the greater trochanter, two periarticular calcifications and one superficial infection. We noted an average improvement in Harris score of 52.3 points (± 6.9) at 03 weeks and 61.5 points (± 7) at 03 months. Conclusion: Our study has shown that total hip arthroplasty by the anterior approach without a traction table or specific ancillary device gives satisfactory outcomes

Backround: The Opera cemented acetabular component was introduced in 1997. It was made of Ultra high molecular weight polyethylene featuring a long posterior wall, a wire marker and a malleable flange. It achieved a 10A* ODEP rating in 2015, despite being withdrawn in 2013. The aim of this ongoing prospective study is to assess the long-term performance of the Opera acetabular component. Methods: Data was collected prospectively on 303 consecutive Opera acetabular implants (275 patients), between March 2000 and February 2005. A posterior approach was used, with a cemented C-Stem femoral component. Palacos-R cement with Gentamicin was used in all cases. All patients underwent annual clinical and radiological review for 10 years then alternate yearly thereafter. Results: Patients with 149 Opera implants died, and 191 hips were followed up for over 10 years. Average follow up of surviving arthroplasties was 185 months. Acetabular revision for aseptic loosening was performed in 14 (4.6%) cases with 17 implants currently loose, all of which are associated with increased wear. Rapid wear was evident in 34% of cases surviving 10 years and 45% at 13 years. 123 acetabular components remain under follow up, with 63 showing rapid wear. Conclusion: National Joint Registries aim to detect failing implants, or institutions, at an early stage. They are, however, based on revision as an outcome and this study demonstrates the shortcoming of this end-point. This study raises concerns about the true long-term performance of the Opera cup and close follow-up of patients with these implants is recommended

The aim of this study was to investigate the difference in bone reaction of each model over a short time period around the porous 3D cup. This case study included 120 Japanese patients (124 hips) who underwent primary total hip arthroplasty with a Continuum (57 hips) or G7 OsseoTi (67 hips) acetabular component. All components were implanted using the press-fit technique after 1 mm underreaming. Radiographic evaluation included spot welds (SW ), a radiolucent line (RLL), gap filling, and bone grafting on the lateral edge of the component one year after surgery. Radiography revealed good osseointegration; thus, SW were obtained in all components of both groups (84% in DeLee zone 1, 72% in zone 2, and 21% in zone 3 with Continuum, 97%, 59%, and 39% with G7 OsseoTi). On the other hand, an RLL with a sclerotic line appeared in 50% of the cases with a Continuum and 44% with a G7 OsseoTi. All of the initial gaps in the nine Continuum cases and 13 G7 were filled with new bone. Morselized bone was grafted in 36 cases in Continuum and 40 cases in G7 OsseoTi that were all well harvested. An RLL with a sclerotic line indicates micromotion between the bone and component. We assumed that an extremely rigid initial fit by the rim with a high coefficient of friction might lead to heterogeneous fixation followed by an RLL. Although both 3D porous components presented with excellent osseointegration, different radiolucencies appeared frequently between the two models.

Introduction: The commonly used devices for fixation of vertical femoral neck fractures are multiple screws or a sliding hip screw with or without an anti-rotation screw. Size, location, and length of the screws are the most effective parameters in terms of structural performance of internal fixation implants, but the optimal configuration of the screws is necessary to be investigated to guide the clinical practice. The aim of this study is to compare the biomechanical stability of two screw configurations, one of which is an inverted triangle and the other one is an “x-crossed” assembly. Methods: A left femur bone model was obtained using a computer tomography scan. The geometry of the bone and bone-screw assemblies were formed using a combination of 3D software. A finite element analysis was carried out for the inverted triangle assembly and “x-crossed” assembly. In the latter, the first screw was positioned close to the inferior cortex of the femoral neck along the axis of the femoral head and the other two screws were positioned close to the anterior and posterior cortex in an “x-cross” shape. Results: Finite element analysis showed that the “x-cross” screw configuration withstands higher von Mises stress while maintaining less shear displacement of the fracture in regard to the inverted triangle configuration which withstands smaller von Mises stress and greater shear fracture displacement. Conclusion: The “x-crossed” screw configuration provides better performance than the inverted triangle configuration in terms of biomechanical stability.

Introduction: Short stems are a bone and soft-tissue preserving alternative to conventional stems. Mid- and long-term results are scarce. The aim of this multicenter study is to present the mid-term outcomes of a calcar-guided short stem. Methods: This is a prospective case series of the first 879 total hip arthroplasties performed on 782 patients across five centers using identical calcar-guided short stems. In a mid-term follow-up (6 years), rates and reasons for complications and revisions were documented. The Harris Hip Score (HHS) was obtained; patients reported pain and satisfaction using a visual analog scale. Results: A total of 43 patients died in the study cohort for non-related reasons; 26 patients (3.0%) required at least one revision after the index procedure. The survival rate for endpoint stem revision at mid-term was 98.4%. The main reasons for stem revision were aseptic loosening and early periprosthetic fractures. Sex had no influence on stem survival. Older patients or those with a high body mass index showed increased risk for stem revision during follow-up. Dorr type A morphology revealed a significantly lower risk of stem revision than Dorr type B or C (p = 0.0465). The HHS, satisfaction, and load pain at mid-term were 96.5 (SD 8.0), 9.7 (SD 0.9), and 0.5 (SD 1.9), respectively. Conclusion: This short stem produced highly satisfactory outcomes at mid-term, with 98.4% implant survival for any cause of stem revision and low complication rates. Long-term results are required to further evaluate these promising mid-term results.

Introduction: Avascular necrosis of the femoral head is caused by impaired vascularization, resulting in the death of osteocytes and bone marrow. The etiology is not yet fully understood. The main risk factor is prolonged corticosteroid therapy. The association with pregnancy is rare. Case Report: A 48-year-old woman, complained with pain in the right hip during her 3rd trimester of pregnancy. After delivery, and due to persistence of pain with limited internal rotation of the right hip, an MRI was performed. It revealed subchondral avascular necrosis of the femoral head, in the antero-inferior area, with about 3,5 cm in diameter, with imminent collapse of the surface (stage II, Ficat classification). Surgical treatment was proposed (decompression using a drill) but was refused by the patient. Conservative treatment was chosen - partial discharge from the right lower limb and pharmacological treatment (calcium carbonate 1500mg + cholecalciferol 400UI id, and ascorbic acid 500mg id). After six months, the patient was asymptomatic - no pain and without hip movement limitation. A new MRI was performed and showed complete resolution of the imaging findings. After two years of follow-up, the patient remains without symptoms. Discussion: The 1st line treatment for Ficat II stage is surgical. Conservative treatment could play a role in early stages of avascular necrosis (Ficat 0-I). However, in the pre-collapse phase, the evolution to collapse occurs in 85% of cases. In this case, conservative treatment was effective, with complete clinical and imaging resolution of the disease.

Aim: While internal fixation remains the gold standard management for extracapsular neck of femur (NOF) fractures, this study assessed whether there is a difference in outcomes between patients undergoing short and long intramedullary nail (IMN) fixation for pertrochanteric fractures. This is particularly novel given our use of 180 mm short IMNs, which are not widely described in the literature, compared to standard long IMNs (340-420 mm). Methods: We performed a single-centre retrospective study of patients undergoing IMN fixation for AO type 31-A1-A3 fractures from January-December 2020. Data was collected from operation notes, theatre and electronic patient records. Subtrochanteric and pathological fractures were excluded. Data was analysed using SPSS. Results: 74 patients underwent IMN fixation, with 38 patients (51%, 31A1-A2) undergoing short IMNs and 36 (49%, 31A1-3) having long IMNs. There was a similar proportion of ASA 3 and 4 patients in both groups. There was a significantly shorter length of operating time with short IMNs, with a mean of 70 minutes, compared to 92 minutes for long IMN (p=0.034). There were no significant differences in rate of transfusion, length of stay, in-hospital mortality, or 3-month post-operative mortality. There was no difference in post-operative implant failure between groups. Conclusion: We demonstrate shorter operating time with short IMNs compared to long IMNs with no statistically significant difference in clinical outcomes. Short IMN fixation is an appropriate treatment for pertrochanteric 31A1-A2 fractures. This finding is particularly relevant to minimizing anaesthetic time for frail patients and in the context of greater theatre pressures.

Background: Digital templating is an essential step in the preoperative planning of total hip arthroplasty (THA). The purpose of this study was to compare the accuracy in the preoperative component selection between the King Mark (KM) calibration device and the conventional metal ball method. Methods: We retrospectively reviewed patients who underwent preoperative digital templating for THA in our center from January 2014 to January 2016 with KM device and marker ball. We compared the preoperative template component size and offset with the intraoperative definite implant size. The accuracy was defined as the difference between preoperative and intraoperative component sizes. Results: 126 THA underwent digital calibration. The overall adequate preoperative planning of the acetabular cup (exact or ± 1 size match) in the KM group did not differ from the single marker method (74.7% and 74.5%, respectively, p = 0.979). No significant difference was noted in the overall accepted calibration of the femoral stem (exact or ± 1 size match) between the groups (58.2% and 70.2%, respectively, p = 0.179). The KM group showed a better preoperative planning for the stem’s offset compared to the marker ball group (77.2% % and 61.7%, respectively, p=0.062). Conclusions: Our study found no difference between the KM method and the conventional metal ball method in the ability to accurately predict component sizes.

Recurrent hip dislocation is one of the most common complications of total hip arthroplasty. Treatment should be customized for each individual. We present a case report of an unusual solution in a revision total hip arthroplasty. A 77-year-old male patient with history of right cementless total hip arthroplasty performed in 2013, who developed hip pain and joint instability with recurrent posterior dislocation of the hip after a fall from standing height. Imagiologic evaluation showed incongruence of the joint, though acetabular and femoral components were correctly positioned. Hence, the patient was proposed for revision hip arthroplasty. During surgery, we found a broken fragment of polyethylene (PE) incarcerated between the PE insert and the femoral head, which belonged to the posterior wall of the insert. So, in order to preserve bone stock, the authors opted for a fallback solution. Cementation was carried out using a constrained polyethylene liner 4 mm lower than the inside of the cementless cup. Surgical intervention elapsed without complications and anti-dislocation preventive measures were applied during the initial months. At seven months postoperatively, clinical and radiographic outcome were remarkably good. The patient was very pleased with the result and no more episodes of dislocation were reported after the surgery (Harris Hip Score of 91 - Excelent). We conclude that cementing an acetabular liner into a well-fixed cementless acetabular shell is a simple, cost-effective alternative solution, allowing the patients to regain pre-injury levels of mobility and early independence in their daily life activities.

Introduction: Management of intracapsular proximal femoral fractures has been based on age, displacement, cognition, and pre-injury mobility. Most surgeons offer arthroplasty rather than internal fixation for these patients irrespective of displacement, to allow early mobilisation and negate the higher rate of reoperation due to failed internal fixation. This study examines whether patients sustaining undisplaced or displaced intracapsular proximal femur fractures represent different patient groups with different pre-injury characteristics and post-operative mortality, irrespective of treatment modality.Methods: A retrospective series of 329 consecutive patients over the age of 55 years who sustained intracapsular proximal femur fractures, who underwent surgical management at a district general hospital over a period of 2 years (2012-2013) were identified using the national hip fracture database. Demographics, American Society of Anaesthesiologist (ASA) grade, pre-injury mobility, cognitive status, and admission serum investigations, fracture displacement, type of surgery, and mortality rates at short term (2 years) & long-term (7-9 years) were reviewed.Results: The median survival in this cohort was 2.95 years (95% CI 2.3-3.6). Mortality rates were 77.4% (n=257) at long-term (7-9 years) follow-up. Admission patient characteristics showed no statistically significant difference between displaced and undisplaced fracture groups. This included ASA, pre-operative cognition, and mobility status. Fracture displacement was not an independent predictor of mortality at short or long term. Conclusion: In patients sustaining intracapsular proximal femur fractures, the degree of displacement is not a caveat for a different patient group. Fracture displacement is not predicted by the pre-injury level of function and does not predict short or long-term mortality.

Introduction
Femoroacetabular impingement (FAI) is characterised by premature contact between the acetabulum and the femur due to abnormal morphology, causing reduced range of motion (ROM) and pain in the hip. The aim of this study was to understand the relationship between version and torsional abnormalities of the acetabulum, femur and tibia in patients with FAI.

Materials and Methods
A systematic review was performed according to PRISMA guidelines using the EMBASE, MEDLINE, PubMed and Cochrane databases for articles relating to version and torsional abnormalities in FAI, Legg-Calve-Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). The study was registered in the Open Science Framework.

Results
A total of 1206 articles were identified from the initial search and finally 55 articles, involving 10,091 hips, met the inclusion criteria for full text analysis. All studies evaluating femoral/acetabular version in FAI reported ‘normal’ mean version values (10 0 to 25 0) An significantly lower in SCFE hips compared to controls (Z=-3.26,P <0.01) In addition, there was limited evidence of acetabular retroversion associated with FAI. Only one study reported an abnormal tibial torsion in 42% of the hips with symptomatic FAI.

Conclusions
Patients presenting with hip pain attributed to FAI were more likely to display abnormal femoral or acetabular version. Paucity of data regarding the association of tibial torsion in FAI warrants further studies in this arena. This high percentage of version and torsional abnormalities highlights the importance of evaluating these parameters routinely during assessment patients with FAI, in order to guide clinical decision making.

Background: Transverse acetabular ligament (TAL) and posterior labrum have been shown to be a reliable landmark to guide optimum acetabular cup position. Acetabular component mal-positioning and oversizing of acetabular component are associated with iliopsoas impingement. The aim was to assess the relationship of the TAL and Psoas fossa (PF) in with respect to Acetabular Component positioning.

Methods: A total of 12 cadavers were implanted with the an uncemented acetabular component, their position was initially aligned to TAL. Following optimal seating of the acetabular component the distance of the rim of the shell from the PF was noted. The Acetabular component was then repositioned inside the PF to prevent exposure of the rim of the Acetabular component. This study was performed at Smith & Nephew wet lab in Watiord.

Results: Out of the twelve acetabular components that were implanted parallel to the TAL, all had the acetabular rim very close or outside to the PF with a potential to cause iliopsoas impingement. Alteration of the acetabular component position was necessary in all cadavers to inside the PF to prevent iliopsoas impingement. It was evident that the edge of PF was not aligned with TAL.

Conclusion: Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. We feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside bone without exposure of the component rim and thus preventing iliopsoas impingement at the PF.

The aim of this study was to identify and evaluate potential risk factors for consecutive neck of femur fracture (NOFF).
Retrospective analyzed NOFF database from 2012 to 2019. Included, patients over 60 years with NOFF. Excluded, Pathological and atypical fractures. 114 patients (4.18%) with contralateral hip fractures out of 2727 NOFF cohort. Mean age 82 years for the first hip fracture and 85 years for the second. Average time interval between two fractures was 36 months. 74.3% of patients had the same fracture pattern on both sides (P<0.0001). 53 patients with cemented hip hemiarthroplasty(CHH) on one side, 31 patients (59%) had a second CHH for contralateral side. Likewise, 48 patients who had dynamic hip screw fixation during the first admission, 33 patients (69%) had the same procedure on the contralateral side too. During the two admissions, no significant difference, length of hospital stay(P=0.30) and median American society of Anesthesiologists(ASA) grades (3). Mean decline in Abbreviated Mental Test Score(AMTS) was 0.4. Clinical Frailty Score(CFS) and Charlson Morbidity Index(CMI) were from 4.5 to 5.9 (P<0.0001), and from 5.4 to 6.1 respectively. Institutional residency increased from 23 to 46 (P>0.0014). The similarity of fracture pattern bilaterally requiring similar surgical procedures were observed. Even though there is minimal or no change in the ASA, AMTS and hospital stay between the two admissions, there is a drastic decline in CFS, CMI and an increase in residential dependency following a subsequent fracture. Our findings demonstrate the importance of emphasizing preventive measures.

Tranexamic acid (TXA) use becomes wider in total hip and knee arthroplasty and spine surgery. Numerous clinical studies have demonstrated efficacy and safety of TXA in proximal femur fracture surgery and shoulder arthroplasty to reduce blood loss and transfusion requirements. TXA use in hip fracture surgery remains a debate and is not the standard of practice yet. We retrospectively reviewed our department`s clinical practice by examining 256 consecutive surgically treated hip fracture patients. 20 consultant surgeons were divided in a group of hip and knee arthroplasty surgeons(n=12) and a second group of surgeons who do not perform lower limb arthroplasty in their elective practice(n=8).TXA was used in 135(52.7%) of all cases. Further review showed that the majority of the cases(58.2%) who were operated by a lower limb arthroplasty surgeon received TXA. Its use was much less popular (32.7%) among the non-arthroplasty surgeons. We concluded that there is a link between the use of TXA in elective arthroplasty and proximal femur fracture surgery. We were unable to identify any documented contraindications for the use of TXA which limits our retrospective study further. Perioperative use of TXA remains controversial among surgeons where consultant anaesthetists seem to prefer it. Moreover, the supervising consultant is occasionally relying on the trainee to brief the team, so the surgeon`s preference may not be truly reflected on this study. We are presenting our results to the consultant body so as to discuss the literature further in an attempt to reach a consensus and establish a local protocol.

OBJECTIVE:
To compare traction with no traction in intertrochanteric femur fractures pre-operatively in terms of visual analog pain (VAS) score.
MATERIAL & METHODS:
All patients presenting with intertrochanteric femur fracture (AO classification 31 A1, A2 and A3) aged 20 to 75 years belonging to either gender presenting within three days of injury were included in the study. Patients were randomized into 2 groups;A and B. Group A underwent pre-operative treatment with skin traction application while no skin traction was applied to the involved lower limb in group B. Patients in the no traction group placed their fractured leg on an ordinary pillow in a position that was most comfortable for them. Primary outcome was pain, which was assessed using VAS (0-10). VAS was determined at 6, 12, 24 and 48 hours after admission. Data was analyzed using SPSS version 23.
RESULTS:
Mean age of patients in the study was 60.93±8.01. Mean age of patients in group A was 65.57±6.46 while in group B it was 59.29±9.11. Majority of the fractures had involvement of right side (n=43). Regarding the type of fracture, 38 (54.3%) had AO 31.A1, 12 (17.1%) AO 31.A2 and 20 (28.6%) AO 31.A3, respectively. Regarding the outcome in terms of VAS score between the 2 groups at 6, 12, 24 and 48 hours of admission, there was no stastically significant difference between the two groups (p>0.05).
Conclusion:
There is no difference in VAS score between pre-operative traction or no traction group in patients presenting with intertrochanteric femur fracture.

Introduction: Total hip replacement is the definitive treatment for end-stage hip arthritis and the templating process is crucial to its success. There are advocates for both two-dimensional and three-dimensional templating methods. Objectives: The aim of this study is 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 or not the currently available methods are sufficiently reliable and reproducible. Methods: Medline, EMBASE and PubMed were searched to identify studies that compared the accuracy of 2D and 3D templating for total hip replacement, followed by a thorough search of the grey literature. Results were screened using the PRISMA flowchart and included studies were assessed for their level of evidence using the Oxford CEBM criteria. Non-randomised trials were critically appraised using the MINORS tool, whilst randomised trials were assessed using the CASP RCT checklist. Results: 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. Conclusions: 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.

INTRODUCTION: Perthes disease is the most common cause of proximal femoral growth disturbance.
In case of leg length discrepancy with a congruent hip joint the Morscher osteotomy is indicated. The altered growth of the femoral neck and the greater trochanteric overgrowth results in a shortened femoral neck called coxa brevis.CASE PRESENTATION: Woman, 39 years old, Hystory of perthes disease. The physical examination revealed hip pain, limping gait with positive trendelemburg sign, loss of hip motion for abduction and rotation and a limb length discrepancy of 3 cm.
Radiography of the hip showed shortened and widened femoral neck with overgrowth of the greater trochanter. The neck shaft angle was varus. CT scan was performed por surgery planification. Morscher osteotomy was indicated. A Guidewire was inserted at an angle of 130º, Three additional guidewires were inserted parallel marking the three osteotomies at the greater trochanter , superior and inferior femoral neck. Three proximal screws were inserted and a lateral plate. A Block of bone graft was impaled by the plate. The Femoral shaft was reduced to the plate producing lateral translation of the distal segment, thereby lengthening the femoral neck and the lower extremity. RESULTS: Clinical follow – up at 6 months shows good evolution with 0.5 cm of leg length discrepancy, pain – free and complete range of motion. DISCUSSION: The Morscher osteotomy has demonstrated good results restoring biomechanics with gait and hip abductor strength improved. Also the hip pain and fatigue resolve.

This study was conducted to determine the clinical utility and success of a dual mobility acetabular device (DM), which have grown in popularity for use in individuals who may benefit from greater range of motion (ROM) and stability. Subjects were followed up at a minimum of 2 years post-operative to assess the dislocation rate of this device and subjects’ HOOS scores (range 0-100). Secondary outcomes included radiographic THA measures, patient satisfaction, Forgotten Joint Score, Harris Hip Score, clinical exam findings, device survivorship, type of bearing (metal or ceramic), surgical approach, and adverse events. The study enrolled 315 subjects, average age of 61.1 years, BMI of 29.7, and an average of 5.3 years post op. There were no dislocations and few adverse events reported; one acetabular implant was removed due to deep infection. Patient reported outcomes supported the hypothesis of positive patient experience with an average HOOS score of 91.9 and a patient satisfaction score of 4.6, between “Very Good” (4) and “Excellent” (5). Radiographic analysis revealed a low frequency of radiolucent lines (RLL) greater than 2mm, with very few RLL of any magnitude on the acetabulum. There was a slightly higher percentage of RLL on the femur, but a majority of these were classified as less than 1 mm. The 0% dislocation rate and positive patient reported outcomes support the use of this DM acetabular construct, with the advantage of excellent stability.

Introduction: Long-term anti-epileptic medication use has been documented as a risk factor for hip fractures due to the associated increased risk of osteoporosis. Previous literature is limited due to either monotherapy evaluation or small sample size. The aim of this study is to evaluate the risk of no treatment (NT), enzyme inducing (EI), or nonenzyme inducing (NEI) anti-epileptic medication and associated hip fracture risk using a large national database. Methods: A review of the Mariner database identified epilepsy patients between 2010 and 2018. Patients were stratified by type of treatment (EI, NEI, NT). Patients were matched 1:1 based on age, gender, Charlson Comorbidity Index, obesity status, alcohol, and tobacco status. Incidence of hip fractures following treatment initiation was measured. Hip fracture, one year costs, readmissions, and revisions were recorded. Outcomes were analyzed via Student T-tests and Chi-square analyses. Results: 33,093 epileptic patients were identified, 4,496 with hip fractures. Patient age, sex, and obesity status were comparable among the cohorts (all, p>0.05). The NEI group reported 17% decreased odds of hip fracture compared to patients prescribed EI or NT (p<0.001). Furthermore, NEI patients reported a $1,981.27 decrease in episode of care cost compared to EI (p=0.65). No significant difference was noted among the groups with regards to readmission (p=0.51) or revisions (p=0.85). Conclusion: To our knowledge, this is the largest database study to specifically evaluate the risk of hip fracture associated with anti-epileptic medication use. NEI anti-epileptic medication was shown to have a decreased odds of hip fracture and decreased costs.

Introduction:
Achondroplasia is a skeletal dysplasia of autosomal dominant inheritance. Fibroblast growth factor receptor 3 mutation at p16.3 locus of chromosome 4 leads to inhibition of sub-chondral growth. Middle aged achondroplastic patient with left fracture neck of femur following a fall of heavy object. It was a challenging case because of coxa-vara and meticulous templating is needed.
Case report:
38 year old male sustained fracture neck of left femur in severe coxa-vara. Closed reduction with 16 mm partially threaded cannulated cancellous screw perpendicular to native neck- shaft angle. At regular follow up, mild lysis was seen around the screw and implant removal was done. Now with neck of femur non-union, walking full weight bearing with walker. The future course included excision arthroplasty or custom made prosthesis.
Discussion:
Achrondroplasia characterised by defects in en-chondral bone formation leading to retarded cartilage growth. Literature search on peri-articular fracture management showed peadiatric disatal femur fracture fixed with percutaneous screws. In adult, neck of femur fracture is managed by percutaneous screw, DHS or prosthesis. Due to altered geometry of proximal femur DHS and Prosthesis was deferred.
Early failure of CC screws in our case is due to perpendicular placement of screws which increased strain due to altered bio-mechanics.
Conclusion:
Achondroplastic dwarfs live a normal life. They are prone to peri-articular fractures because of anatomical variations. We wanted to highlight the difficulties and importance of pre-op planning and implant choice of fracture fixation in an adult achondroplasia patient.

Introduction: We hypothesized dual-mobility (DM) cup could limit the risk of total hip arthroplasty (THA) dislocation in patients with displaced femoral neck fracture (FNF). Methods: We selected patients 1) with a Garden III or IV FNF; 2) an age between 65 and 75 years; and 3) a minimal 12-month followup. One hundred and nine patients (33 males, 76 females) (109 hips) were included, with a mean age of 69.6 ± 3 years (65 to 75). Patients were matched for age, sex, and BMI with OA patients (control). All patients had a DM-THA through a posterior approach.
Results: Fifteen patients (15 hips) had died at a mean of 22.4±11 months (16-68). Complications included an infection (9), a dislocation (4), and a periprosthetic fracture (2). At a mean of 40.2±10 months (12-80), mean Postel Merle d’Aubigne score was 16.8±1.7 (10-18). Function was rated at least good in 87% cases. Postoperative Parker and Devane scores were 7.8±0.5 (1-9) and 2.2±0.7 (1-3), respectively. Comparatively to the control, the rates of additional procedure and mortality were higher in the FNF group (13% vs 3.7%, 14% vs 3%, respectively, p<0.001), with no dislocation and better function in OA patients (p=0.008). A cup malposition was found in 3 out of 4 dislocation cases. Conclusion: As anticipated, mortality and complication rates were higher in the FNF group than in the control. When the cup was inserted in the recommended safe zone, the DM system was associated with < 1% dislocation rate in FNF.

Although Tranexamic Acid (TXA) is proved to be safe to use and efficient to reduce transfusion rates in both elective arthroplasty and proximal femur fracture surgery,trauma surgeons still debate over its use for hip fracture patients.We attempt to investigate the effect of TXA on postoperative transfusion and haemoglobin(Hb) levels following hip fracture surgery and its popularity among our surgeons. Retrospective cohort study including consecutive hip fracture patients who were treated surgically between July and December 2020.Demographics for two groups (TXA use vs control) were reviewed. We have also studied the type of fracture and procedure,pre and post-operative Hb and the need for blood transfusion.256 patients(172 women, 84 men) were included. Mean age of 81.8 years old(range 47-102 years).123 patients were treated with hip hemiarthroplasty,14 received a total hip replacement,36 had an intramedullary nail and 83 have undergone extramedullary internal fixation(dynamic or cannulated screws).TXA was given in 115(44.9%) cases.52 patients required a transfusion in the control group and 25 in the TXA group(36.8% vs 21.7% transfusion rate).Mean Hb drop on first post-operative day was 23.8 vs 15.4 g/dl in control and TXA groups respectively.We found that TXA used in patients undergoing hip fracture surgery reduced the drop in postoperative haemoglobin and the need for postoperative blood transfusion.Pre-operative haemoglobin value, age, and type of surgery were risk factors for erythrocyte transfusion independent of treatment group.The TXA is not routinely used for hip fracture surgery in our department and bigger trials assessing for potential complication and determining the ideal regime would be beneficial.

Background: Perioperative corticosteroid administration is associated with reduced postoperative nausea and vomiting, postoperative pain, and enhanced recovery following surgery. However, potential complications including wound and periprosthetic joint infections (PJI) remain a concern for surgeons following total joint arthroplasty (TJA). Methods: A systematic review of the search databases PubMed; google scholar; and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk following perioperative corticosteroid administration in total joint arthroplasty. PRISMA guidelines were utilised for this review. Meta-analysis was used to assess infection risk according to joint and corticosteroid dosing regimen used. Results: 201 studies were returned following initial search strategy, with 29 included for review following application of inclusion and exclusion criteria. Studies were categorised as using low or high dose corticosteroid with single or repeat dosing regimens. Single lose dose corticosteroid administration was not associated with an increased risk of infection (p=0.4; CI=0.00-0.00). Similarly, single high dose corticosteroid not associated with an increased infection risk (p=0. 3; CI=0.00-0.01) nor did repeat low dose regimens result in any increased risk of infection (p=0.8; CI=-0.02-0.02). No significant risk difference in infection risk was noted in either hip (p=0.59; CI= -0.03-0.02) or knee (p=0.2; CI=0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. Conclusion: Use of perioperative corticosteroid in total joint arthroplasty does not appear to be associated with an increased risk of postoperative infection in patients with limited co-morbidities. Further research is warranted to evaluate postoperative complications following TJA in these at-risk patient populations.

Introduction: We present series of cases where we use CT scan to make 3 D preoperative planning in primary total hip replacement. Objectives: This method gives us information which implant is best for the patient, help us about size of implants , anteversion, inclination, bone density, center of rotation positioning, limb length equality, femoral offset and shows us possible complications.Study Design & Methods: A report on a series of patients with an outcome of interest. We present main points in planning and main difficulty between computer planning and real surgery. Results: In all patient was use exactly the same implant as planned. Our first few cases we had difficulty to determine exactly the same neck resection as it was planned. It 2 cases we have complication - put acetabular component more proximal as well center of rotation is more proximal. We don't have intraoperative periprosthetic fracture , any dislocation or infection. Conclusions:
Preoperative planning is the future of joint replacement surgery. It gives us exact size of implants - that mean faster surgery shows us eventually complications for example- bone density, dysplasia of the femur or acetabulum. Bone cyst in area of acetabulum will make difficulty for press fit

Background: We hypothesize highly variable non-standardised perioperative management of direct oral anticoagulants (DOACs) in patients with proximal femoral fractures to be associated with unnecessary time-to-surgery (TTS) delays and an avoidable increase in mortality in this group.
Methods: We performed a retrospective analysis of collated data in the orthopaedic department of a district general hospital. All appropriately injured patients that underwent surgery within a calendar year were identified and further subgroups defined: 1. control 2. anticoagulation – warfarin 3. anticoagulation – DOACs. Systems were interrogated to establish accurate admission to anaesthetic room timelines for all patients. A delay was defined as any surgery which took place beyond thirty-six hours. A cancellation occurred when a patient previously listed and booked for theatre was adjudged to not yet be fully optimised.
The end points assessed were TTS, general anaesthesia, neuraxial anaesthesia, thirty-day mortality and one-year mortality. Local performance was compared to the national average published on National Hip Fracture Database for the corresponding year.
Results: 284 proximal femur operations were completed in 2018. Twenty-three patients on warfarin, aged 70-95years, average 85.3 years, female to male preponderance 15:8. 20 patients on DOACs, aged 69-96, average 84.8 years, female to male preponderance 14:6. Average TTS-warfarin 38h20m, average TTS-DOAC 45h30m, DOAC-delay 60%, DOAC-cancellation rate 50%, DOAC 30-day mortality 10%, national average 6.6%.
Conclusion: Non-standardised perioperative management of DOACs in neck of femur fractures contributes to unnecessary TTS delays and mortality. Robust systems and ubiquitous cross-specialty protocol must be generated to prevent such delays wherever possible.

Background: Position of a lag-screw in a fixed-angle sliding hip screw is related to failure of fixation with increasing tip-apex distance (TAD) significantly correlated to rate of cut out of the lag screw. TAD is used to describe the position of the screw in relation to the apex of the femoral head. Aim: Measure TAD for dynamic hip screw (DHS) done for pertrochanetric fractures of the femur and compare to the chosen standard. Methods: Between January 2019 and October 2020, 187 patients underwent DHS for extracapsular hip fracture. The mean age of patients was 85.3 years. TAD was measured with correction for magnification as the sum of distance between the tip of the lag screw and the apex of the femoral head on anteroposterior and lateral radiographs. Comparison was made to standard of TAD of 25mm or less as per Baumgaertner et al. Results: The mean TAD was 17.02±5.3mm with maximum TAD recorded of 41mm and minimum of 7mm. 94.65% (n=177) of DHS had a TAD of 25mm or less. Conclusion: In conclusion, the present study shows excellent compliance to the standard. Though there is no routine follow up for hip fractures in the elderly no incidence of cut out or other complication recorded.

Objective: To examine measurement properties (inter-rater reliability, agreement, validity, and responsiveness) of the Cumulated Ambulation Score French translation in patients with hip fracture. Design: Methodological study. Setting: A 20-bed orthopedic unit and 20-bed geriatric unit. Subjects: About 140 consecutive patients with a mean (SD) age of 83 (12) years. Interventions: The English version of the Cumulated Ambulation Score used to evaluate basic mobility was translated into French following international guidelines. Two raters independently assessed all patients on postoperative days one, two, three, and 30 after a hip fracture surgery. Relative and absolute inter-rater reliability and responsiveness (effect size for improvement from postoperative day two to 30) were evaluated. Convergent validity was analyzed by Spearman’s correlation coefficient comparing the Cumulated Ambulation Score with two other measures on postoperative day two and 30. Main measure: Cumulated Ambulation Score. Results: The weighted Kappa value ranged from 0.89 to 1.0. The standard error of measurement and the smallest real difference of the Cumulated Ambulation Score ranged, respectively, from 0.12 to 0.23 and from 0.32 to 0.6 points, while the effect size reached 1.03 (95% CI 0.87–1.26). There was a strong positive correlation comparing the Cumulated Ambulation Score with the French Tinetti Assessment Tool (r ⩾ 0.83) and the French Mini Motor Test (r ⩾ 0.79). Conclusions:
Our findings indicate that the Cumulated Ambulation Score’s French version is a reliable and valid tool to assess patients’ basic mobility with hip fractures.

Introduction: Hip fragility fracture patients are susceptible to substantial blood loss with 20-60% of patients requiring allogeneic blood transfusions, which carries significant risks and morbidity. Intraoperative use of tranexamic acid (TXA) was shown to reduce blood loss in numerous orthopedic procedures. Data on TXA efficacy in trauma patients undergoing proximal femoral nail (PFN) fixation are controversial. This study was designed to assess the efficacy and safety of intraoperative TXA use in patients undergoing PFN fixation as treatment for intertrochanteric femur fracture. Methods: All patients who underwent PFN fixation in a tertiary-medical center between 2011-2019, with a minimum follow-up of 3 months. The cohort was divided into "TXA group" and "non-TXA" group. Blood loss, readmissions and mortality were compared. Results: Of the 1848 consecutive patients (69.2% females) who underwent PFN fixation, 526 (28.5%) were in the "TXA group" and 1322 (71.5%) were in the "non-TXA" group. Intraoperative TXA use was not associated with 30-day mortality (4.4% vs. 4.6%, respectively, p = 0.82), 30-day readmission (7.4% vs. 8.8%, p = 0.34) or change in hemoglobin levels before and after surgery (Δ-3.64 gr/dL vs. Δ-3.74 gr/dL, p = 0.20). Moreover, blood replacement (packed cells) was significantly higher in the TXA group (13.3% vs 9.2%, p <0.01).
Conclusions: In a large retrospective study, in contrast to the known effect of TXA in other orthopedic procedures, the use of TXA in patients undergoing PFN fixation was not associated with either a clinical or a statistically significant reduction in blood loss, mortality or readmission rates.

Nonunion and delayed union of femoral neck fractures are causes of increased morbility and mortality. Arthroplasty is a commonly used option. In young patients, due to their functional demand and component wear, other techniques try to preserve joint function and functional capacity for an adequate quality of life. We presented a 55-year-old man with surgical history of valgus osteotomy for femoral neck fracture nonunion, thirty years ago. In the follow-up, pain and progressive functional limitation of the hip are observed with trendelenburg gait. Radiography showed osteonecrosis of the femoral head. The angled plate was removed and a total hip arthroplasty was performed. He is undergoing a rehabilitation program with 95º flexion hip range of motion and mild pain. Femoral neck fractures can be associated with nonunion in almost 30% of young patients, especially in more vertical orientation (Pauwels III) and varus collapse. Valgus intertrochanteric osteotomy consists in "horizontalizing" the fracture line, converting vertical shear forces into compression forces. This procedure has good functional results in 70-90% of patients, at medium term. Hip arthroplasty after osteotomy can also have excellent clinical results. However, it’s associated with a longer surgery and a higher complication rate. The improvement of materials for total hip arthroplasty can make it a better choice for a young. In this case, although the conversion to arthroplasty is almost inevitable, keeping the native joint in these 30 years has allowed the patient a good quality of life without major functional deficits, during most of his working age.

Around 1.5 million people in the world have had metal-on-metal(MoM) hip implants. There have been rising concerns about these particular hip implants due to a higher revision rate when compared to the conventional prostheses. Aim: To study the indications for revision in patients with MoM hips as there are no robust guidelines or evidence regarding the same. Methods: We retrospectively analyzed 281 patients with MoM hip implants (Total hip replacement and Resurfacing) operated at a District General Hospital over a period of 20 years. Of the cases that were revised, we reviewed the following factors: clinical progress, blood levels of Cobalt/Chromium and radiological imaging including radiographs, MRI. Results: Approximately 20% of the patients with MoM hips had been revised till date. We observed that 29.16% of all Total Hip replacements and 14.10% of all Resurfaced hips had been revised. Our data suggests that 15 patients were revised for loosening alone, 13 patients were revised for elevated bloods and 9 patients were revised only on clinical grounds. 9 patients had more than one issues. 4 had to be revised due to other reasons like periprosthetic fracture, dislocation. A reduction in blood metal ions was observed after revision. All patients had good clinical outcome post revision. Conclusion: The decision to revise metal-on-metal hips is complex which requires clinical, laboratorial and radiological correlation and warrants regular follow up.

Background: The accuracy of pre-operative digital templating for total hip arthroplasty (THA) using the diseased versus unaffected contralateral joint remains unclear. As such, we devised a study to compare templating precision between the operated hip joint versus the healthy side for patients with osteoarthritis (OA). The study hypothesis was that preoperative templating accuracy of THA on the ipsilateral diseased hip joint would be higher compared to the contralateral healthy hip in patients with OA. Materials and Methods: We retrospectively reviewed 100 patients who underwent THA for unilateral OA at our center from January 2018 to January 2020. Retrospective preoperative digital templating was performed separately on both the operated hip joint and the healthy contralateral hip joint by a single surgeon who was blinded by the in-situ components sizes. Accuracy of each group was compared to the implanted components. Results: Assessment of the 100 included cases demonstrated superior acetabular component size prediction when templating was performed using the diseased hip compared to the healthy contralateral side (68.0% versus 51.0%, p<0.001). No differences between the cohorts were found regarding templating accuracy of femoral stem sizes (72.0% and 69.0%, p=0.375) or neck offset (73.0% and 69.0%, p=0.289). Conclusions: Templating acetabular cup size using the ipsilateral diseased hip is more accurate than using the contralateral healthy hip in patients with unilateral OA.

Background: From 2016-2019, 4 patients developed hip infections post-hemiarthoplasty. However, within 5 months (Oct 2020 to Feb 2021), 6 patients developed hip infections following hip hemiarthroplasties for fracture neck of femur. Aims: To establish the root causes and key learning from the occurrence and use the information contained within this report to reduce the likelihood of a similar incident in the future. Methods: 65 patients presented with a neck of femur fracture between 2020-2021, of which 26 had hemiarthroplasties and 6 subsequently developed hip infections. Hospital records and post-hip infections guidelines from the Royal College of Surgeons and NICE (National Institute for Health and Care Excellence) were utilised in data collection. Results: Proteus, Enterococci and Staphylococcus Epidermis were identified as the main causal organisms present in hip infections. On average, ward moves was 4 with 90% of patients developing COVID-19 during their admission. Microbiology input was fundamental in this analysis to provide information about the cause of the hip infection organisms identified. Having had 5 of 6 patients growing enterococci suggests contamination of the wound either due to inadequate wound management in the non-surgical wards or excessive ward transfers during COVID 19 pandemic period are potential causes for increased rate of infection. Conclusion:
Rate of hip infections was increased due to COVID-19 infection, in combination with excessive ward transfers against the trust guidelines and lack of experience amongst non-surgical healthcare staff in the management of post-operative wounds. Multidisciplinary team education is essential to minimise further risk and patient safety overall.

Introduction: One of the modalities used to decrease the incidence of postoperative infection is skin scrubbing with antiseptics including betadine and chlorhexidine. This study compared the antiseptic efficacies of betadine and chlorhexidine in decreasing the risk of infection after THA. Materials and methods: In this double-blind clinical trial, 102 patients underwent THA were assigned randomly to two equal groups. In the first group, betadine was used to scrub the skin preoperatively. In the second group, chlorhexidine was utilized. The incidence of postoperative wound complications were compared between two groups. Results: Two groups were the same in term of age and sex. There were 3 (two superficial and 1 deep) and 1 patients (superficial) with postoperative wound infection in betadine and chlorhexidine group, respectively. The difference was not significant (p=0.617). The signs of infection included secretion, erythema, fever and blisters. Discussion: Although there are several studies regarding the efficacy of antiseptics in prevention of infection, however, the efficacy of betadine and chlorhexidine were limitedly compared, specially in the field of hip replacement. In a systematic review in 2019, Ho et al demonstrated that waterless hand rub and chlorhexidine had higher antiseptic efficacies compared to povidone-iodine. However, the current study did not confirm the findings of Ho et al. It seems that more studies are required to compare the efficacy of these antiseptic agents in prevention of wound complications after THA. Conclusion: Both betadine and chlorhexidine are effective substances to scrub the skin before THA to reduce the risk of postoperative infection.

The basis of the work was the analysis of the results of 158 cases of revision hip arthroplasties in 152 patients with aseptic losening. Shell loosening was observed in 65 cases (41.1%), stem losening was observed in 50 cases (31.6%), both components were instabil in 43(27,2%). Most of endoprostheses were destabilized between 5 and 9 years after the primary surgery. Recurrence of aseptic instability was observed only in 7 cases, 5 of which (71.4%) were with cement type of fixation. In the case of total instability, no difference in the results was observed with the use of exclusively primary components and in the combination of primary components with revision reconstructive systems. After 10 years a significant majority (35 cases, which was 81.4%) were cases with preserved component stability (t=7.3, p<0.05). The recurrence of instability of one component was observed in 8 cases, which represented 18.6% of the total number of revisions. In patients with instability of acetabular and femoral components, in the presence of bone defects I-II according to Paprosky, the results of the revision replacement were the best when implanting primary components with cementless type of fixation. With Paprosky type III acetabular and femur bone defects, the results were best achieved with the use of revision anti-protrusion acetabular and elongated femoral modular or monoblock systems with cementless type of fixation. Applications for the revision of components with cement type of fixation had significantly worse results compared to cementless ones and much shorter life.

Introduction: The clinical course of subchondral fatigue fracture of the femoral head(SFFFH) is not well known. Most studies about SFFFH are case series within 10 cases. We retrospectively evaluated the clinical course of SFFFH and the factors affecting it in large number of patients. Methods: We evaluate the patients diagnosed with SFFFH via radiographs and magnetic resonance imaging from October 2000 to January 2019. Patients who had undergone surgery before visiting our institution or lost to follow-up before the recovery were excluded. We analyzed 89 hips in 80 patients consisting of 51 males and 29 females. The following data were collected from the medical record and radiographs: patient demographics, time to visit our institution from the hip pain, time to recovery through conservative treatment, collapse of the femoral head, osteoarthritic changes, and hip dysplasia. Linear and logistic multiple regression analysis was conducted. Results: 82 cases(92.1%) improved their hip pain with conservative treatment, and seven cases(7.9%) underwent surgery. Patients improved on average 2.9 months. Conservative treatment was effective for patients(68 out of 68 patients) who visited the hospital within six months from the hip pain and had the collapse not exceeding 4mm. Conservative treatment was not effective for SFFFH patients(5 out of 9 patients) who visited the hospital for more than six months from the hip pain and had a collapsed femoral head. Conclusions: The success of conservative treatment of SFFFH can be predicted through the degree of the collapsed femoral head and the time of beginning conservative treatment.

Introduction: There is a paucity of literature regarding the impact of iron deficiency anemia (IDA) on patients undergoing femur open reduction and internal fixation (ORIF) surgery. The purpose of this study is to evaluate the impact that IDA has on femur ORIF patients. Methods: This study retrospectively analyzed the New York State’s Statewide Planning and Research Cooperative System database between the years 2009-2013 to isolate 33,719 patients undergoing femur ORIF with minimum 2-year surveillance. These femur ORIF patients were then split into two cohorts (n=1190 each) using 1:1 propensity score matching based on age, race, gender, payment methods, and Charlson-Deyo-Comorbidity-Index (CDCI). Patient demographics, perioperative variables, and postoperative outcomes (surgical complications, medical complications, readmissions, reoperations, in-hospital mortality) were compared between the two groups. Univariate and multivariate binary logistic regression analysis adjusting for age, gender, race, payment method, and CDCI were utilized to evaluate IDA as an independent predictor of postoperative outcomes for patients undergoing femur ORIF. Results: The IDA group had longer total length of stay (days) compared to the non-IDA group (9.0 vs. 8.0; p=0.016). In addition, the IDA group had higher rates of overall surgical complications, wound complications, postoperative transfusion of blood, pulmonary embolism, and reoperation (all p<0.05). Conclusion: IDA is found to be a significant predictor of postoperative complications and reoperation after femur ORIF surgery with 2-year surveillance. Total length of stay is also higher in patients with IDA. Surgeons should be aware of the impact that IDA may have on their patients undergoing femur ORIF.

BACKGROUND:
Pain remains the biggest contributor to poor postoperative recovery in enhanced recovery pathway following lower limb arthroplasty. We thus conducted a study to compare the efficacy of Oxycodone and morphine in successful multimodal pain management in these patients.
MATERIAL AND METHODS
A multidisciplinary prospective study was conducted at United Lincolnshire NHS trust (ULHT) for consecutive patients undergoing primary lower limb arthroplasty via enhanced recovery pathway. Two cohorts of patients were established; one receiving NSAIDS and the other not receiving NSAIDS. Patients who had been operated from Jan 2018 to December 2018 received Oxycodone (10mg) and patients operated from January 2019 to March 2019 received Morphine (10 mg). The following parameters were recorded on 1st day post op & on discharge; pain score (VAS), eGFR, and side effects and compared with appropriate statistical analysis.
RESULTS:
A total of 772 patients were included of which 347 underwent total hip arthroplasty and 425 total knee arthroplasty . 58% of these patients received NSAIDS (ibuprofen or Naproxen). The difference in pain score was non-significant either at day one or at discharge (p=0.12, 0.18). Higher eGFR was noted with use of morphine, however it was non-significant (p=0.08, 0.16). The cumulative side effects was found to be significantly higher in patients receiving morphine in both the cohorts (p<0.01)
DISCUSSION:
Our study indicates that the use of oxycodone in these patients can prove to be an effective regime for multimodal analgesia as it has similar efficacy in terms of pain control with reduced postoperative side effects.

Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants. Intramedullary fixation is the treatment of choice for this type of fracture. Although, proximal trochanteric fixation is not always straightforward, especially when the fracture line extends proximally. We describe 2 cases of multiple fragment subtrochanteric fractures, treated with Distal Femoral LCP (locking compression plate) in a reversed situation: e.g., left plate for right hip. Both fractures couldn´t be reduced by close reduction in a traction table and proximal lateral femur needed to be open exposed to reduce the fracture. Because of the proximal and distal fracture extension, anatomic plates such as proximal femoral locking compression plate may not provide enough stability due de few proximal screws. To resolve this issue, we used a reversed LCP anatomic distal femoral allowing an anatomical reduction with proper fixation. The shape of a reversed contralateral distal femoral plate fits well with the contour of the greater trochanter and the shaft of the plate fits well with the anterolateral curve of the femur. The distal femoral plate may be considered as alternative for the treatment of unstable subtrochanteric fractures because it provides proper fixation of the lateral fragments, prevents the lateral migration of proximal fragments and stable fixation with more number of proximal screws.

Background: Osteosynthesis of non-displaced femoral neck fracture (FNF) in the elderly population is an alternative to arthroplasty. The newly available Femoral Neck System (FNS) currently lacks evidence of effectiveness compared to the gold standard Triple screw construct (TS) and the Dynamic Hip Screw system (DHS). This study evaluates short term clinical and radiological outcomes after osteosynthesis using TS, DHS and FNS. Methods: patients aged ≥ 75y with a non-displaced FNF were included in this single-center retrospective non-randomized study. Patients were treated with either TS, DHS or FNS. Duration of surgery, number of packed red blood cells transfused, surgical complications, length of stay, discharge location, medical complications, readmission within 30 days, and mortality within 3 months were extracted from patients’ charts. Radiological analysis assessed fracture impaction and proximal femur shortening at 3 and 6 months. Results: the TS (n=32), DHS (n=16) and FNS (n=15) groups were similar. No significant differences across groups for need for blood transfusion, surgical site complications, length of stay, postoperative medical complications and readmission within 30 days, discharge location and mortality within 3 months. Duration of surgery was lower in the FNS group (43.3 vs 68.8min; p<0.001). Radiological assessment found similar impaction (5,2mm +/-4.8) and shortening (8.6mm +/-8.2) in all groups that did not seem to progress after 3 months. Conclusion: The FNS appears to be an alternative implant for FNF osteosynthesis and is associated with shorter operative time than TS and DHS. Short-term clinical and radiological outcomes of FNS are similar to TS and DHS implants.

Dislocation of the hip joint in adults is usually caused by high-energy trauma such as road traffic accidents or falls from heights. Posterior dislocation is observed in most cases. We report a rare case of a 78-year-old male who had a posterior hip dislocation without trauma. The patient with a history of high-grade invasive/infiltrative urothelial carcinoma presented to our emergency department with dyspnea and sudden right hip pain while lying in bed. He was observed by internal medicine department. An abdominal, pelvic and thoracic computed tomography was performed to identify the cause for dyspnea. On the CT scan we found out a posterior dislocation of the right hip. The patient denied any fall or even minor trauma. Closed reduction of the dislocated hip joint was immediately performed with pain relief. Given the history of invasive carcinoma in the pelvis and low muscular hip support caused articular instability therefore reducing the amount of energy necessary for a dislocation to occur. This case highlights awareness of the occurrence hip dislocation in low demand patients and the importance of clinical examination and radiographs of joints even with no trauma associated.

The optimal method of fixation for bipolar hip hemiarthroplasty (BHH) particularly fixation with or without cement is still controversial. We conducted a retrospective observational study where information was collected from 400 patients with an intracapsular fracture of the proximal femur who underwent BHH from 2017 to 2019, in a single institution where press-fit fixation is largely used. The objective was to compare the results between cemented and cementless prostheses. The outcomes studied were intraoperative and postoperative peri-prosthetic fracture, periprosthetic infection, implant dislocation, mortality in the first 30 days, and mortality at one year. The average age was 85.5 ± 8.5 and 28,5 % were male. A total of 27 patients were submitted to cemented BHH and 373 patients were submitted to cementless BHH, Hardinge approach was the most used, the Watson-Jones approach was used in 19 patients, and the posterior approach in two. Results from cemented prosthesis were: 14,8% of 30 days mortality rate; 33,3% one-year mortality rate; one patient had an intraoperative peri-prosthetic fracture and there were no cases of periprosthetic infection or prostheses dislocation. Results from cementless prostheses were: 7,2% of 30 days mortality rate; 27,3% of one year mortality rate; 4,0% of the patients had an intraoperative peri-prosthetic fracture; 1,0% had postoperative peri-prosthetic fracture; 1,6% had prostheses dislocation and 2,7% had periprosthetic infection. The average age was the same in both groups, but since only 6.75% of the prostheses in our series were cemented, there is not enough statistical volume to relate the complication rate with cementation.

Introduction: Traumatic hip dislocation associated with ipsilateral femur neck and acetabulum fractures are a rare & devastating injury as a result of high energy trauma with potential complications of avascular necrosis of the femoral head and secondary osteoarthritis of the hip joint. Patients postoperatively may encounter a serious challenge in terms of functional outcome and activities of daily living. Treatment options include either internal fixation or primary arthroplasty. Avascular necrosis of femoral head and secondary osteoarthritis of hip joint remains major issues with internal fixation. Case Presentation: A 45 year old patient was diagnosed with posterior hip dislocation with ipsilateral femur neck and acetabulum fracture. Plan for emergent hip reduction and primary surgical fixation of fractures was made. Intra-operatively posterior wall acetabulum fracture was found to be excessively comminuted non-amenable for fixation and femoral head was found to be avascularised. Subsequently, plan was changed to total hip replacement with acetabular defect reconstruction. At 1 year follow-up no aseptic loosening was found on AP view of pelvis with total Harris Hip Score of 91. Conclusion: Early operative management for such complex injuries is a necessity. Definitive management in form of primary fracture fixation/arthroplasty should be decided intra-operatively.

Posterior hip dislocation with concomitant Pipkin fracture is a rare clinical entity, which dictates prompt reduction and fixation so as to have the best chances of preserving the viability of the native femoral head. Closed reduction attempts should be minimal and with extreme caution due to a reported high prevalence of iatrogenic fractures. There is ongoing debate concerning fixation of the femoral head fracture or primary total hip arthroplasty after reduction is achieved, depending on variable factors. We report a case of a young adult with traumatic posterior hip dislocation and an ipsilateral Pipkin type II fracture following a high speed motor vehicle collision accident, who sustained an iatrogenic fracture of the femoral neck while undergoing attempts aimed at closed reduction of the hip under general anaesthesia, thus accidentally converting it to a type III. The decision to proceed with a primary total hip arthroplasty was made intraoperatively. Preliminary results at six moths follow up are promising as the patient has returned to his work place and life style.
We go through the latest reports in the literature in regards to this type of injury while attempting at the same time to provide some insight on how best to avoid intraoperative unfortunate events and manage these challenging clinical emergencies.

Poliomyelitis is a highly infectious viral disease largely affecting children, which invades the nervous system, resulting in muscle paralysis. Wide spread vaccination programmes have achieved almost complete eradication of the disease. Despite this, individuals infected during childhood still exist and many have developed a persistent paralysis of the lower limb. Deformities of load bearing joints are common, either on the paralysed side or the non-paralysed side. When performing Total Hip Arthroplasty, physicians expect a higher degree of postoperative complications, such as dislocation or component loosening, mainly due to muscular imbalance as well as a dysplasic acetabulum and femoral neck-shaft angle. Despite this, such complications have not been reported in patients with residual poliomyelitis, possibly due to lack of published cases. In this article, we present a clinical case of a 64-year-old male with residual poliomyelitis who sustained a fall, resulting in femoral subcapital fracture of the right hip. Despite the paralysis on the injured side, the patient was previously autonomous and capable of gait using a crutch. Radiographs show the fracture site and a dysplasic hip with increased femoral neck-shaft angle. Cementless total hip arthroplasty was performed, using a double mobility femoral head implant, as well as a conical metaphyseal engaging stem, with care to maintain previous limb length discrepancy. Post-operative evolution was satisfactory. During follow-up, the patient resumed daily life activities with no pain or functional limitation reported so far.

INTRODUCTION: Retrospective analysis of Fracture neck of femur fixed with 2Holed DHS was done at our institute. Radiological outcome of including complication rate and conversion to total hip arthroplasty was assessed. METHODS: We audited number of patients that underwent 2holed DHS over a 6year period and calculated the complication rate including conversion to total hip replacement. After the end of first cycle we implemented a change as per NICE guidelines and fixed Garden type 1 valgus impacted fractures with 2Holed DHS. The patients for followed up for a period of 18 months in the second cycle and in both cycles, we compared our practise against literature. RESULTS: 1st cycle(retrospective) – 28 patients, time period 4 years. Conversion to THR – 2.6%, 1 Patient, 55/m, 2h+DS, AVN, Converted to THR @ 1 year. Complication - 2.6%, 1 patient, 85/F- Lag screw cut out, had hemiarthroplasty which dislocated and finally converted to Girdlestone. Patient Died 3 weeks later to due medical co-morbidities.2nd Cycle(prospective) –9 patients, time period 18 months. This was done prospectively after implementation of change and both conversion to THR/Complication rate was nil.
DISCUSSION & CONCLUSIONS: We concluded that 2 holed DHS fixation for a Garden -1 Valgus impacted fracture neck of femur was a safe and acceptable option. However, we would like to assess the patients physiological age, mental status and act in accordance to the NICE guidelines before venturing down the fixation route.

Introduction: One-stage bilateral THA (BTHA) offers many benefits. However, there are concerns about the safety of the procedure and higher complications. We aimed to evaluate the complications and outcomes of one-stage BTHA with Harding approach for femoral head avascular necrosis (FHAVN) patients. Methods: A total of 60 patients (44 men and 16 women) with bilateral FHAVN were underwent one-stage BTHA through Harding approach. The patients aged 31.4±4.1 years. A prospective analysis of the functional outcomes and complications was performed. The patients were evaluated clinically and radiologically in serial follow-ups. The modified Harris Hip Score (MHHS) was performed preoperatively and postoperatively. Results: The mean surgical time was 2.6±0.4 hrs. The mean hospital stay was 3.5±0.7 days. Hemoglobin level decreased significantly after the operation (15.2±3 mg/dL versus 12.2±2.7 mg/dL; P= 0.046). There was no reported patient with perioperative death, deep venous thrombosis, pulmonary embolism, infection, dislocation, periprosthetic fracture or heterotrophic ossification. The mean preoperative MHHS score was 47.93±7.33 which significantly increased to 95.1±3.5 in the last follow-up (P=0.0001). Conclusion: One-stage BTHA through Harding approach is a safe and useful treatment for patients with bilateral FHAVN. However, long term studies are necessary.

OBJECTIVE: Minimizing the risk of complications after this rare and severe operation.
METHODS: Eighty patients with primary tumors of the pelvic region were diagnosed and treated between 2004 and July 2020, at the Emergency Hospital” St Pantelimon”, Bucuresti Romania. Out all of these, fifty were incisional biopsies, 19 excisional biopsies, 7 inter-ilio-abdominal disarticulations for chondrosarcoma, and 4 pelvic resection – reconstructions (2 chondrosarcoma, 1 malignant histiocytoma and 1 hydatic cist). We will refer to the Inter-ilio-abdominal disarticulation for the chondrosarcoma only – 7 cases. The diagnostic was obtained by incisional biopsy, after complex imagistic investigations: pelvic CT and MRI, Bone Scintigraphy, Thoracic CT, Pelvic X-ray.
RESULTS: All of the 7 patients analysed in this work survived intraoperatively and during the first six months postoperatively, but in 2 out of the 7 patients, one or several complications were recorded. We will present the details complications.
CONCLUSIONS: The inter-ilio-abdominal amputation would offer a survival rate but the patients and the surgeons must know all the complications morbidity rates and death probability. The inter-ilio-abdominal amputation is a difficult surgical procedure for the surgical team and for the patient, as well as technically exhausting and requires a good preparation and warning of both the surgeon and the patient about the high incidence of complications. The quality of treatment by this method is undertaken by the effort of a multidisciplinary team, which possesses the necessary experience and technical equipment in the field of bone tumours.

Synovial chondromatosis is a rare synovial disorder characterized by the presence of benign loose bodies in the joint space. The affliction of the hip joint is rare. This entity usually goes undiagnosed as it is largely asymptomatic till complications like secondary osteoarthritis secondary to degenerative changes, subluxation of hip and fracture neck of femur ensue. Here is a 46-year-old farmer presented with a nine-year-long history of left hip pain with restriction in flexion, extension and internal rotation. He was diagnosed with synovial chondromatosis and had a history of undergoing arthroscopic debridement following which he was asymptomatic but relapsed after 6 months. We performed excision with uncemented modular bipolar hemiarthroplasty after confirming the diagnosis on plain radiographs and computed tomography. Significant recovery in the range of motion was noted post-operatively and the patient showed no signs of relapse in the follow-up period of 2 years.

Bisphosphonates, despite reducing the risk of osteoporotic fractures and having a beneficial effect in the long term, reduce bone turnover and allow the arising of microfractures that accumulate over time. The authors present a case of a 74 years-old woman that was admited on the emergency department for severe pain on her right hip, denying trauma. Diagnosed with atraumatic intracapsular right femoral neck fracture. According to the patient history, she suffered a previous intracapsular femoral neck fracture on her left hip, five years earlier, due to a low energy trauma, having received a total left hip replacement. Patient was treated with Ibandronic Acid 150mg daily since 1999, and had a previous diagnosis of osteoporosis. Patient underwent right femoral hip replacement and this time, the therapy with bisphosphonates was suspended. She is now fifteen weeks post-op, remaining without any complication. Atraumatic femoral neck fractures are rare, since the majority of atypical femur fractures are observed in the lateral aspect of the subtrochanteric or femur diaphysis, explained by the accumulation of tensile stress in these areas. After the diagnosis of atypical fracture, bisphosphonates intake should be discontinued. These drugs cause excessive suppression of bone turnover and elasticity decrease, and this is considered to be central to the development of atypical fractures. Although it is not possible to establish a direct relationship between long-term use of bisphosphonates and atypical femoral neck fractures, given the absence of trauma, we should consider this new variant, in order to diagnose and treat them accordingly.

Background:This study compares the management of patients with periprosthetic (PP) fractures versus those with fractured neck of femurs (FNOFs) in a district general hospital.

The FNOF pathway, managed by the National Hip Fracture Database (NHFD), sets a national standard for patient care. Despite similar care requirements, there is currently no pathway for PP fractures. A PP pathway was due in 2020 by the NHFD but is yet to be established. This study aims to add to current evidence to support implementation of a PP pathway (Bottle et al,2020).

Methods:Electronic health records were used to collect data on 51 lower-limb PP fracture patients (January 2018-February 2020), including length of stay, 30-day mortality, time-to-theatre and care assessments.

Results:32% of surgically treated patients had time-to-theatre within 3 days. Average time-to-surgery was 5.4 days with 57% of patients surgically treated.
Comparing PP vs FNOF patient care: Average Length of Stay (24.8 vs 13.9 Days), Mortality Rates within 30 Days of Discharge (9.8% vs 6%).
Average completion of care assessments: Geriatric(15.7% vs 99.5%), Bone-Health(3.9% vs 99.8%), Cognitive(9.8% vs 98.9%), Falls(13.7% vs 100%), Nutrition(11.8% vs 97.3%), Delirium(11.8% vs 99.2%), Physiotherapy(92.2% vs 99.7%).

Conclusions:These results highlight significant disparities in the care of PP fractures vs FNOFs, including lower assessment completion rates, longer times to surgery, higher mortality rates and greater lengths of stay. Further improvements in the management of PP fracture patients are required. Critically, the disparity in care may be attributed to the lack of a coordinated multi-disciplinary team approach, the cornerstone of the FNOF pathway.

Introduction: The PFNA-2 are being used for inter-trochanteric fractures worldwide. The demographic data shows Asian population have an increased anterior bowing of the femur. Long PFNA-2 tip impinges the anterolateral femur shaft, which can cause multiple complications: posterior displacement of the proximal fragment, increased surgical time and blood loss, anterior thigh pain, distal anterior cortex fractures. This study evaluates functional and radiological outcome of Short thin PFNA-2 in type 1 and 2 classification of intertrochanteric fracture by Boyd and griffin in old age (> 65 years) Asian population. Methodology: Functional and radiological outcome of 50 patients treated with short and thin PFNA2 for above mentioned inter-trochanteric fractures between January 2017 to December 2019, were evaluated prospectively. Functional results and pain were evaluated using Harris Hip Score (HHS) and visual analogue scale (VAS). Radiological outcome was based on union of the fracture. Follow up was carried out at regular intervals till 1 year. Results: The mean HHS was 85.6 and VAS score was 2.16 (p < 0.0001). 1 patient each in blade cut through, blade backout and infection group. The mean operating time was 37 min. The mean blood loss was 120 ml, mean duration of hospital stay was 2.54 days after surgery. Mean time to union was 4.5 months. Conclusion: Short and thin PFNA2 suffices for type 1 and 2 classification of intertrochanteric fracture by Boyd and griffin in old age Asian population and prevents aforementioned complications. Keyword: PFNA-2 Proximal Femoral Nail antirotation and anterograde.

Intracapsular proximal femur fractures are one of the commonest fractures encountered in the lower limb. The majority need osteosynthesis with suitable implants and intraoperative positioning over the fracture table is preferred for ease in fracture manipulation, traction, reduction, and fluoroscopic assessment. However, positioning of the limbs of a bilateral above knee amputee for internal fixation of associated proximal femur fracture is a daunting task and needs customized inventory for effective limb positioning and fracture manipulation. This case report describes a rare presentation and technical tips in the management of acute presentation of the neck of femur fracture in bilateral above-knee amputation following bilateral lower limb crush injury in a road traffic accident. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided neck of femur fracture with multiple Cancellous Cannulated Screws.

Total hip arthroplasty (THA) is the treatment of choice for the patient suffering from end-stage hip osteoarthritis. In grossly shortened osteoarthritic limb deformities preforming a THA is a difficult task and demanding and the result could vary. We compared two methods restoring the anatomical acetabulum vs high hip centre component placement technique. We did this comparative analytical study in between December 2016 to January 2020 over 17 patients with grossly shortened limb deformities (minimum 3 cm shortening). We randomised the patients with Odd and Even method anatomical (n=8), high hip centre (n=9). We have to do sub trochanteric osteotomy in 4 of our anatomical cases due to difficulty during reduction. We avoided active hip abduction in all of our subtrochanteric osteotomy cases. We managed 2 cases in high hip centre with tenotomy. There is no major complication other than a delayed union in one case in osteotomy site. THA in patients with gross shortening is a demanding operation associated with higher failure and revision rates. A detailed preoperative planning is very important. Our main goal is restoration of the anatomic hip centre which serves to restore abductor lever arm and pelvic imbalances thus eliminating abnormal contact stresses on the hip joint.. With the advances in technology, THA is becoming a very valuable option but it still can prove to be a technically demanding operation even for experienced surgeons.

Introduction
Segmental fractures of the neck of femur (SFNOF) are rare injuries that should be recognized early.

Case presentation
We present a series of two cases with SFNOF who initially underwent surgical fixation with a femoral intra-medullary nail. Both cases had complications of fracture non-union, femoral intra-medullary nail failure and migration, and had to undergo revision surgery with a hip arthroplasty.

Conclusion
A discussion of similar cases in the literature is presented. We highlight the importance of early recognition and appropriate further imaging such as computed tomography (CT) scanning and consideration of arthroplasty options.

Keywords: segmental fractures of neck of femur; early recognition; revision arthroplasty; computed tomography imaging

Pseudotumors are a known complication of metal-on-metal (MoM) total hip arthroplasty (THA).
We present a case of a 62-year-old patient.
After primary implantation, the patient presented 16 years later with a cup loosening.
Prior to revision surgery, CT scan was performed, which showed a new solid mass, likely a MoM related pseudotumor, reaching from the left hip into the pelvis.
2 years later a prosthesis joint infection (PJI) was suspected, due as a joint sample showing Staph. Epidermidis. Revision surgery showed no infection.
After 6 months the patient presented with recurrent posterior dislocation requiring inlay exchange.
3 weeks later the patient was readmitted with massive exudation and drop in haemoglobin.
The performed CT scan showed only the known mass. The patient was treated as a PJI with debridement and implant retention, no active bleeding was found intraoperatively.
Prior to surgery CT-Angio was obtained, showing again no active bleeding. Haematological disorders were ruled out.
Bleeding continued, and with an active blood loss of unknown origin, the patient was referred to the University Hospital of Basel.
After several further revisions without stopping the bleeding the pseudotumor was suspected to be the origin of the blood-loss, the mass was excised en bloc as R2 resection showing an angiosarcoma. Post R2 resection there were no further surgical options. Palliative radiotherapy was performed, stopping the bleeding.

After this case, we recommend to confirm the diagnosis of a pseudotumor with MARS-MRI and histological analysis of every unknown mass resected in joint replacement surgery.

Title- Operative technique to use anatomic landmark to recreate horizontal and vertical offset in total hip arthroplasty

Background-
The success of total hip arthroplasty is directly related to recreation of pre-existing anatomy. Authors president of technique to recreate horizontal and vertical offset using pyriformis tendon as landmark.
Technique-
The procedure is performed by posterior approach to hip. The standard approach is carried until pyriformis tendon is identified. Using methylene blue a transverse mark measuring 2- 3 mm width is made on pyriformis tendon 1 cm proximal to insertion into femur. Pyriformis is tenotomised at this mark to approach the hip. The procedure of total hip arthroplasty is carried out as planned until trial implants. After trial reduction, the marks on pyriformis tendon are aligned to check if anatomy is restored. The procedure is completed once surgeon is happy with the offsets.
Conclusion-
Authors present a simple simple, easy, reproducible technique to recreate pre-existing anatomy. We understand, this is a soft tissue landmark however experienced surgeon can assess tension in the tendon before tenotomy and at the time of closure. It can be used as adjunct with other methods to assess horizontal and vertical offset.

Introduction: A 49-year-old male patient, office clerk by occupation, presented with right hip pain for 4 months following a fall at home. The patient had a history of road traffic accident 1 year back following which he was operated on with an ipsilateral below-the-knee amputation, along with a right distal femur shaft fracture managed with a retrograde femur nailing. Method: Radiological investigations revealed a right neck of femur fracture non-union, right distal femur shaft fracture non-union with distal femur nail in situ. The distal femur nail was removed and the distal femur non-union was plated in compression mode with bone grafting. The neck of femur fracture was managed with a Primary Total Hip Replacement as the definitive procedure. Results: The patient was rehabilitated with a below-knee prosthesis and could resume his routine activities independently 3 months after the surgery. Conclusion: An ipsilateral neck of femur fracture in below-knee amputation with distal femur shaft non-union is an uncommon entity. It was managed with primary total hip replacement and distal femur plating with allogenic bone grafting to avoid any possibility of repeat surgery and give the best possible outcome with an aim to last for the rest of his life.

Introduction: This study aimed to analyze the incidence and risk factors for aspiration pneumonia in hip fracture patients with surgical treatment.

Material and method:
The medical records from 836 the hip fracture patients ≥ 65 years of age who underwent surgical treatment between 2005 and 2021 were acquired from a hip fracture cohort of the single institution. A total of 836 patients (618 female and 218 male) with average aged 79.6 years were enrolled. Patient’s demographic factors, past medical history including chronic obstructive pulmonary disease, interstitial lung disease and asthma, preoperative Koval score, Chalson comorbidity index (CCI), and known risk factors for aspiration pneumonia in previous studies were analyzed. Factors associated with surgery were also evaluated. Comparison analysis was conducted between the patients with and without aspiration pneumonia to confirm the risk factors for aspiration pneumonia by logistic regression.

Results: The mean age of the patients was 79.6 years (range 65–100 years). Aspiration pneumonia was confirmed in 2.51% (21/836) of the patients with average 81.48 years. Their average ICU stay was 1.29 days, and 3 patients died before discharge. In multivariate analysis, male, Parkinson’s disease, longer duration of hospitalization, and postoperative 3 to 5 days higher serum BUN and lower serum albumin level were statistically significant. (P 0.002, 0.013, 0.002, 0.027, and 0.003)

Conclusion:. The incidence of aspiration pneumonia was 2.51% and the mortality was 0.4%. Aspiration pneumonia was important complication, and physician should pay attention to prevent aspiration pneumonia.

Background: The Nottingham Hip Fracture Score (NHFS) is a scoring system developed in 2007 to predict 30-day mortality after hip fracture surgery following a neck of femur fracture. It consists of 7 parameters to predict mortality; age (66–85 and ≥86 yrs); sex (male); number of co-morbidities (≥2), admission mini-mental test score (≤6/10), admission haemoglobin concentration (≤10 g dl−1), living in an institution; and the presence of malignancy. Aims: To assess the accuracy of the NHFS against the National Hip Fracture Database during the COVID-19 pandemic. To explore whether it should it be routinely included on admission to aid clinical management. Methods: NHFS was retrospectively calculated for 50 patients who had a fractured neck of femur between January 2020 to March 2020. 1-year and 30-day postoperative mortality data were collected from hospital records and NHFD scores gathered from national statistics.
Results: Overall mortality was 6.06% at 30-days compared to the NHFD score of 6.80%. 1-year mortality was 22%. A NHFS of <5 was considered low risk and a score of >/5 high risk. Survival outcomes were worse in the high-risk group at both 30-days and 1-year. COVID-19 infection was more prevalent in the high-risk group with a higher NHFS. Conclusion: The identification of high-risk groups from their NHFS can allow for targeted optimisation and care. It is a useful predictor to stratify the risk of 30-day and 1-year mortality after hip fracture surgery. Inclusion of the score should be can help aid clinical management and improve patient safety overall.

Introduction: Dual mobility cups are becoming common practice among arthroplasty surgeries. Dual mobility cups have aimed to reduce postoperative hip dislocation especially in high risk patients. The purpose of this study is to evaluate the outcome of dual mobility cups in treatment of displaced femoral neck fractures through assessing the rate of dislocation as a primary outcome and evaluate the patient’s quality of life by Harris Hip Score as a secondary outcome. Methods: This is a retrospective study included Forty-six patients (47 hips) with femoral neck fracture treated by dual mobility cup arthroplasty. Outcome evaluation was done radiologically to evaluate dislocation or any mechanical failure and clinically using Harris Hip Score in 3 months at least post-operative. Results: No dislocations or mechanical failure were reported during an average follow-up duration of 12.98 ± 8.46 months (range 3.0-36.0). The average post-operative HHS was 70.42 ± 19.10 out of maximal score of 100 (range 4.4-98.0). Conclusion: Dual mobility cups showed promising results regarding post-operative stability in a short-term follow-up in patients with fracture neck of femur especially in those with high risk of dislocation.

Introduction: Hip prosthetic surgery is current nowdays. Operative indications have become increasingly frequent given the development of operative techniques and of hip prostheses.
The objective of our study was to evaluate quality of life of the patients undergoing bilateral total hip arthroplasty (THA) assessed by SF-36 questionnaire. Methods: We carried out a descriptive analytical study at orthopedics and traumatology department on patients who had bilateral THA for non-traumatic coxopathy. Patients were admitted between 01/01/2013 and 30/06/2018. We collected data from patients’ medical files to calculate PMA score and we used telephone interviews to answer SF-36 questionnaire in its validated arabic version. Results: We collected 31 patients with a mean age of 54 years and sex-ratio of 1,58. Coxarthrosis was the most common etiology with 64,5% of the cases, followed by rheumatoid arthritis and ankylosing spondylitis. The mean PMA went from 9 to 13.9 after surgery. The SF-36 with its two physical and mental components went from 10.06 ± 7.01 to 49.52 ± 20.34 and from 18.25 ± 12.46 to 61.93 ± 20, 57 respectively with a significant difference for the 2 scores. We have found that comorbidities are associated to poor quality of life. Conclusion: Bilateral THA improves the patients’ quality of life significantly. Using a score to assess quality of life with functionnal scores for patients with coxopathy allows better planification of their management.

Ninety percent of native hip dislocations are posterior dislocations. We present an unusual case of a young patient who sustained a posterior hip dislocation with a low energy trauma. An 18-year-old male presented to the emergency department with great pain in his left hip after falling from his height when playing football. He didn’t present any other traumatic injuries. X-ray revealed a left posterior hip dislocation with an apparent very small acetabular posterior rim fracture. Immediate closed hip reduction was performed under fluoroscopy. Computed tomography revealed intraarticular bony fragments. The patient was operated 1 week later with removal of the intraarticular bony fragments by hip arthroscopy converted posteriorly in an open anterior approach due to the impossibility of removing the fragments arthroscopically. Post-operatively, the patient completed a comprehensive course of physiotherapy. At eight months, the patient returned to play football with a score of the Hip dysfunction and Osteoarthritis Outcome Score (HOOS) in the field of Function, sports and recreational activities of 92 (0-100). We present an unusual case of a posterior hip dislocation with an atypical mechanism of low- momentum collision in native hip joint. This rare diagnosis is classically associated with younger patients whose bones are strong enough to dislocate rather than fracture in the setting of a high-momentum collision. Prompt reduction of the dislocated hip, within 6 hours, is recommended. Taking into account the presence of intra-articular bone fragments in a stable hip of a young patient, the surgery was performed in order to prevent future osteoarthritis.

INTRODUCTION: We examined if red blood cell distribution width (RDW), mean corpuscular volume (MCV) and mean platelet volume (MPV) may serve as predictors of postoperative mortality in elderly patients with proximal femoral fractures (PFF).

METHODS: The cohort comprised 1574 patients aged >65 years who underwent surgical treatment for PFF during 2015-2018. RDW was considered a dichotomous variable (< and >14.5%), MCV and MPV were considered continuous variables.
RESULTS: The mean age was 83.6±1.89 years; 68.7% were female. Most patients (1085/1574, 69.1%) underwent closed reduction internal fixation, 414 (26.4%) underwent bipolar hip replacement and 71 (4.5%) total hip replacement. At admission, 576 patients (36.6%) had higher RDW levels and 998 (63.4%) had lower levels. Age, sex, and surgery type and duration did not differ between these groups. Patients in the high compared to the low RDW group presented with more comorbidities (p<0.001) and more abnormal laboratory test results. Overall mortality within one year after surgery was 17.5% (276 patients). For patients with high compared to low RDW, and with higher than lower MCV level, all-cause mortality was higher at 3 months (p=0.001 and p=0.0001), 6 months (p<0.0001 and p=0.0001) and one-year post-surgery (p<0.0001 and p=0.0001). No significant correlation was found between MPV levels and mortality. Forty-four (2.8%) patients had postoperative infection, without significant association to baseline RDW, MCV or MPV levels.

DISCUSSION AND CONCLUSION: Combined with other clinical and laboratory findings, preoperative RDW and MCV levels may serve to improve risk stratification of elderly patients to be operated for PFF.

Introduction: Day case arthroplasty has gained increased traction in recent years, freeing up hospital beds and reducing healthcare costs whilst maintaining excellent outcomes. The Coronavirus pandemic has forced a rethink of elective surgery in order to minimise inpatient stays and address the backlog of patients on waiting lists. Our aim has been to facilitate the restart of lower limb arthroplasty surgery during the pandemic by introducing day case surgery at our average-sized district general hospital. Methods: Criteria were outlined to identify patients that may be suitable for day case arthroplasty surgery. Appropriate patients were counselled in the outpatient clinic, given preoperative instructions and listed accordingly. Preoperative narcotics were ceased, and patients commenced on anti-inflammatories, neuropathic analgesia and high-calorie drinks two days prior to admission. Patients were discharged on a predetermined analgesic combination based on their bodyweight. Followup was made by telephone the same night and later in the week, and in person at 6 weeks. Results: Between October and December 2020, all total hip replacements (THR) that were planned as day cases went ahead successfully, representing 54% of THR cases and 37.5% of all joint replacements performed by the senior author. Total length of stay ranged from 9 to 12 hours. There were no readmissions, good pain control and excellent patient satisfaction. No patients contracted Coronavirus during their hospital journey. Conclusions: Our experience of introducing day case surgery at our hospital has thus far been successful and will be expanding to include total knee replacements in the near future.

Aim of the study: The aim of this study is to identify if there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for neck of femur fractures. Patients and Methods: Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. Pathological fractures and patients treated with other treatment modalities were excluded. The study population is composed of four groups; patients with no neuromuscular disorders, patients with Parkinson’s disease, patients with previous stroke, and patients with dementia. Results: A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe dementia with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson’s disease was statistically significant (p=0.02) while none of the other neuromuscular conditions were statistically significant. Conclusion: Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson’s disease in comparison to other groups. No increase was apparent for those with dementia or weakness from a previous stroke.

Introduction
The purpose of this study was to conduct a systematic review and meta-analysis to analyse the outcomes following surgical management of FAI by the following techniques, hip arthroscopy, anterior mini open approach and surgical hip dislocation.

Materials and Methods
This systematic review has been registered with PROSPERO. An electronic database search of Pubmed, Medline and EMBASE for English and German language articles over the last 20 years was carried out according to the PRISMA guidelines. We analysed a patient reported outcome measures, α-angle, rate of complications, rate of revision and conversion to total hip arthroplasty.

Results
A total of 48 articles were found suitable for final analysis Thirty two of these were for the angle post-operatively with a mean change of 28.8° (95% CI,21°-36.5°;p <0.01) after AMO, 21.1° (95% CI,15.1°-27°;p <0.01) after SHD and 20.5°(95% CI, 16.1°-24.8°;p <0.01) after arthroscopy. All subgroups reported a significant increase in PROMs. The AMO group showed a significantly higher increase in PROMs versus arthroscopy (p <0.01) and SHD (p <0.01). The rate of complication after AMO was significantly higher than arthroscopy and SHD.

Conclusions/Discussion
All three surgical approaches for the treatment of FAI, arthroscopy, AMO and SHD, offered significant improvements in outcomes and radiological correction of cam deformities. Whilst AMO demonstrated the largest improvement in PROMs, there was a similar correction in alpha angle measurements across all groups. All three groups showed similar rates of revision procedures,
but both arthroscopy and SHD had relatively low rates of complications.

Introduction
To reduce perioperative complication rates and to quickly reintegrate the patient into everyday life, so-called fast track programs have been introduced. The aim of this retrospective case-control study was to identify patient characteristics and patient-independent factors that influence fast track programs in hip arthroplasty.
Materials and Methods
A total of 1138 patients were examined. The main objective of this case-control study was the number of hospital days. A hospital stay of more than seven days was used to define the case group.The causes for longer hospitalisation, metadata (age, sex, and BMI), chronic nicotine and alcohol abuse, ASA score, surgical duration, anaemia and blood transfusion, and concomitant diseases were assessed. The statistical analysis included two-sample t-test, chi-square test and logistic regression analyses. Additionally, 95% confidence intervals were calculated (p<0.05).
Results
The analysis revealed that 16.9% of patients could not leave the hospital on the seventh day. The main causes of extended stay were delayed wound healing (69.4%), increased CRP (43.0%>100 mg/l), and internal complications (19.7%). At a mean of 69.2 ± 10.7 years, the age of the case group was significantly higher than that of the control group, which had a mean of 63.3 ± 10.3 years (p<0.001). Cardiac comorbidities (p<0.001), BMI (p=0.023), and alcohol consumption (p<0.001) increased the risk for longer hospitalisations. Additional significant patient-independent factors were duration of the surgery (p<0.001) and transfusion (p<0.001).
Conclusion
Longer hospitalisation and delayed discharge must be taken into account for patients with advanced age, cardiac comorbidities, alcohol consumption, and high BMI.

Introduction: The British Orthopaedic Association’s (BOA) ‘Blue Book’ does not recommend the routine practice of hip precautions following hemiarthroplasty for neck of femur fractures. Valuable therapist time is utilised alongside the need for specialised equipment, which can potentially delay discharge. Aim: To explore the current practice of hip precautions on discharge following hemiarthroplasty for hip fractures across trauma and orthopaedic departments in the UK. To assess the necessity of hip precautions and identify any areas for improvement. Methods: An online survey was distributed to trauma and orthopaedic trainees from CT level to Consultant across 26 different UK trusts. The survey included both closed and open questions. Overall, 55 responses were collected over a four-month period. Results: 72.7% of respondents were aware of the ‘Blue Book’ recommendations, but 76.4% did not commonly follow hip precautions for post-hemiarthroplasty patients. In addition, 84.9% did not notice any increased risk for dislocations in the absence of hip precautions. 76.4% felt hip precautions should not be practiced and 85.5% agreed that patients failed to comply with hip precautions. Recommendations included changing the practice to follow the BOA guidance and to instead be included as post-operative advice. Conclusion: Hip precautions are not widely regarded as a useful practice for post-hip hemiarthroplasty. They are viewed as increasing costs and resources when they are being implemented as mandatory practice. Thus, this potentially delays discharge overall and increases the risk of patient’s acquiring hospital-acquired infections. A consistent approach should be followed in treating patients’ post-hip hemiarthroplasty across all trusts.

Background:Proximal femoral fractures (PFF)are among the most common injuries treated by orthopedic surgeons in the elderly population. Postoperative complications, especially infections, are of great importance due to their effect on patient mortality, morbidity and healthcare costs. This study aimed at assessing and identifying major risk factors and other demographic and clinical variables associated with an increased infection rate after surgical treatment of hip fractures in the elderly.
Methods:We conducted a retrospective analysis PFF patients in our medical center between the years 2015 and 2017. Medical records were divided into two groups, namely with or without postoperative infection during immediate hospitalization and 30 days after surgery. Factors such as time from admission to surgery, duration of surgery and length of stay were analyzed.
Results:Out of 1276 patients, 859 (67%)underwent closed reduction internal fixation, 67 (5%)underwent total hip arthroplasty and 350 (28%)underwent hemiarthroplasty. 38 (3%)patients were diagnosed with postoperative infection. The demographics and comorbidities were similar between the study groups. The incident of infection was the highest among patients undergoing hemiarthroplasty (6%, p<0.0001). Length of hospitalization (15 vs 8 days, P=0.0001)and operative time (117 vs 77 min, P=0.0001)were found to be the most significant risk factors for postoperative infection.
Conclusions:In our cohort, predisposition to postoperative infections in PPF patients was associated with prolonged length of surgery and longer hospitalization. Our clinical conclusions from these results is to optimize the process of fast discharge, select the appropriate type of surgery, and improve surgical planning to reduce intraoperative delays and length of surgery.

Introduction: Total hip arthroplasty is performed to treat the diseases of hip like osteoarthritis, inflammatory arthritis and osteonecrosis and helps to achieve complete pain relief and notable improvement in function.Objective:To compare functional outcome between ceramic on polyethylene vs metal on polyethylene in total hip replacement.Methods: This was a single centric, observational, prospective study. The study was conducted for a period of 36month from January 2018 to December 2020.All the patients who are undergoing Total Hip Replacement for isolated hip pathologies at our hospital.
Age between 30 – 80 years.15 patients underwent surgery with ceramic on polyethylene and 15 patients underwent surgery with metal on polyethylene as bearing surfaces in total hip replacement. Modified Harris hip score was used to assess the functional outcome in our study. Results: The harris hip score in both the groups showed improvement post THR. ThePre operatively 86%in ceramic and 93%in metal had a poor score. The result showed a significant improvement post operatively, wherein 80 % in ceramic and 53.44 % in metal had an excellent score and 13 % in ceramic and 33 % in metal showed good and 6 % in ceramic and 13 % in metal showed fair results. No patient had a poor score.Conclusions:The outcome of total hip arthroplasty is 
determined by multiple factors.Our study suggests that the current generation 
implants can provide satisfactory outcome after an intermediate duration of follow-up.The overall functional and clinical outcome of ceramic on poly was better than metal on poly weight bearing surfaces.

Introduction: Dislocation of total hip arthroplasty (THA) is the second most common complication after surgery. There are a variety of techniques described in the literature for closed reduction of THA with a very low incidence of complications. This case report describes a case of a total displacement of the acetabular component as a complication of closed reduction of THA. Case Presentation: Female patient, submitted to a total right hip arthroplasty,uncemenmted, using a posterolateral approach. Patient undergoes rehabilitation without complications and on the 4th postoperative day suffers a fall, presenting with pain in the right hip, shortening and internal rotation of the right lower limb. Radiography reveals posterior dislocation of right THA. Allis reduction maneuvers were performed. After the reduction attempt, the right lower limb appears without shortening or rotation, apparently with successful reduction. A radiography was performed and it showed a total displacement of a migrated acetabular component anteriorly and inferiorly in the thigh. The femoral head was located in the acetabular cavity. Discussion: Displacement of THA after closed reduction is rare and have been described 6 cases in the literature, referring to migration of the femoral stem. We could not find any case of total displacement of the acetabular component after reduction attempt. This case is presented not only for its rarity but also to alert surgeons of this serious complication that exposes the patient to a new surgery. An delicate reduction, under sedation and with the support of fluoroscopy, is safer and prevent the occurrence of these complication.

Introduction: The concept of the ‘weekend effect’ remains controversial; several large-scale studies have claimed that admission to hospital at the weekend leads to higher mortality but many other studies show no correlation. Fractured Neck of Femur (NOF) remains one of the most common orthopaedic presentations, and it is widely acknowledged that delays in treatment lead to increased mortality. Our aim was to determine if admission for fractured NOF at the weekend (Friday – Sunday) had any impact on time to surgery or 30-day mortality, compared with admission during the week (Monday – Thursday). Method: Retrospective review of all patients over 60 admitted with fractured NOF. Patients were identified from in-house NOF database; data on demographics, treatment and mortality were obtained from electronic records systems. Results: 342 patients, average age 81 years, M:F ratio= 1:2; 202 admitted Mon-Thu, 140 admitted Fri-Sun. There was no statistically significant difference in 30-day mortality between patients admitted during the week (4.5%) and the weekend (6.4%) (p=0.4).
From the weekday cohort, 156 (79.2%) were treated within 36 hours, (average= 33 hours). From the weekend cohort, 114 (86.4%) patients received surgery within 36 hours (average= 27 hours) (p=0.1). Conclusion: Our results demonstrate no significant difference in 30-day mortality, or time to surgery when comparing patients admitted during the week or the weekend and thus do not support the concept of the ‘weekend effect’. With effective surgical planning and multidisciplinary care, patients admitted with fractured NOF receive a good standard of care, irrespective of day of admission.

Mastocytosis is an uncommon myeloid malignancy. Signs and symptoms are caused by the release of biological mediators from MC and infiltration of neoplastic MC in different organs. The skin and the bone marrow are predominantly involved.
Total Hip Replacement (THR) in a patient with systemic mastocytosis (SM) is a rare occurrence.
A 38-year-old male with SM was referred to our outpatient clinic with severe pain in the left hip, especially on weight-bearing. He had urticaria pigmentosa skin lesions and signs of bone marrow infiltration including bruising, bleeding and anemia. Anteroposterior pelvic radiograph showed diffuse sclerosis and the medullary canal seem obliterated. Obvious features of osteoarthritis were present in the left hip.
The general condition of the patient was good and the life expectancy was considered reasonable, therefore a cemented THR was performed. We observed significant bleeding from the soft tissues. The definition of the medullary canal was difficult due to the unusual bone density, whereby the preparation of the femur was done using fluoroscopy. With three years of follow-up, he has a normal gait; slight, occasional pain, with no compromise in activity; HHS 96 of 100 [excellent]. There are no radiological signs of loosening.
To date, there are only two cases reported in the literature of patients with SM undergoing THR. According to this results and having in mind that osteoporosis is the most prevalent bone manifestation in this scenario. Intraoperative fluoroscopy was valuable to get the correct alignment and size of the femoral component.

Since the assumed titanium wear problem in 36mm ceramic-on-ceramic bearings in THA (as presented by myself as a preliminary study not including all cases at the AAOS 2018, New Orleans, USA), now 21 THA with symptomatic titanium metallosis were now successfully surgically revised from 36mm ceramic-on-ceramic bearing to a 32mm ceramic-on-polyethylene bearings. In all cases black titanium particle stained tissues and symptomatic synovitis was found and excised. All cases had presented with highly elevated titanium ions, as in the venous blood tests that were carried out. Revision surgery was required due to pain, pseudotumor and implant loosening. Histopathology had confirmed metal particles in all tissue samples. All patients (100%) reported better scores and next to zero symptoms following revision/conversion surgery. These recent data provide more evidence, that the titanium taper wear in 36mm CoC bearings in THA is related to existing symptoms and/or implant loosening in those cases. Furthermore, these data suggest, that 36mm CoC Biolox delta bearing couples in THA play a significant role in causing titanium metallosis, painful synovitis and aseptic implant loosening. Ergo, surgeons still utilizing 36mm CoC bearings should monitor their patients annually and check for symptoms, titanium ion levels in blood serum and radiolucent lines particularly at the femoral stem-bone-interface. These data should encourage all surgeons, who utilize 36mm CoC Biolox delta ceramic bearing in THA, to monitor their patients annually. The data of this study also indicate, that, perhaps, the use of 36mm CoC should be avoided in THA.

Objectives
The shapes and concepts of fixation on short stem are various. The purpose is to clarify the differences on clinical and radiographic performances by comparing five-years’ clinical results of three concepts of short stem.
Materials & Methods
Two hundred four patients who were underwent THA by three different types of short stem were enrolled between 2012 and 2014. There were 167 females and 37 males. The average age at operation was 65 years old. The average follow-up term was 72 months (60-84 months). Ninety-six percent was osteoarthritis of the hip. Patients were classified into three groups (Tapered short (TS): 76 hips, Calcar-loading short (CL1): 65 hips, CL2: 63 hips) by the type of stem concept. Clinical hip score and radiographic stem stability and bone reactions around the stem such as spot welds and stress shielding to the proximal femur were estimated.
Results
Preoperative and five years’ clinical hip scores in TS/CL1/CL2 groups were respectively 42/47/47 and 91/95/92 points. Spot welds of postoperative five years were observed in 45-75 % of TS group, 70-100 % of CL1 group and 73-97 % of CL2 group. Postoperative five years’ stress shielding (TS/CL1/CL2 groups) were respectively judged as none in 0/9/1 %, 1st stage in 10/56/26 %, 2nd in 65/35/58 %, 3rd in 15/0/13 % and 4th in 5/0/0 %.
Conclusions
Better bony ingrown fixation and more decreased stress shielding could be observed in CL1 and CL2 groups, which might be attributable to calcar loading by double curved shape of CL short stems.

Introduction: In recent years the role of vitamin D3 in health of different organs of the body, specially, musculoskeletal system had been increasingly studied. It has been reported that the serum level of vitamin D3 may affect the outcomes of total hip arthroplasty (THA). The aim of this study was to evaluation of the changes in serum vitamin D3 levels before and after THA in Iranian patients from 2016 to 2018. Methods: This cross-sectional study was performed on 100 patients with osteoarthritis underwent THA. Serum level of vitamin D3 before and four weeks after the surgery were measured and compared. Results: The mean serum level of vitamin D3 in patients was 24.72 nmol / lit preoperatively, which increased significantly to 31.86 nmol / lit at the end of 4th postoperative week (p-value <0.001). It was showed that age, sex and approach of the surgery did not significantly contribute to the elevation of serum level of vitamin D3. Conclusions: The current study showed that patients who had higher levels of vitamin D were more likely to experience increased vitamin D after surgery. Also, the trend of postoperative vitamin D changes according to preoperative follows a linear trend.

INTRODUCTION: Few controlled studies explore proximal femoral geometry and risk for acquiring proximal femoral fractures, especially among the elderly. Previous reports still reveal multiple inconsistencies. OBJECTIVE: To establish if there is an association between radiographic hip geometry and risk for proximal femoral fractures based on measurements taken from elderly Filipino women. METHODS: A prospective, cross-sectional study of 182 Filipino women ≥ 60 years old at a single orthopedic institution last 2019-2020 was done. Patients were categorized into those with femoral neck fractures (n=84), intertrochanteric fractures (n=64), and those without diagnosed hip fractures (n=34). Standard pelvic radiographs done and the following radiographic parameters were compared: hip axis length (HAL), femoral neck length (FNL), neck shaft angle (NSA), horizontal offset (HO), femoral head diameter (FHD), and femoral neck diameter (FND). RESULTS: Data suggests increased FND increased the risk for acquiring both femoral neck (OR = 1.31, p = .011) and intertrochanteric fractures (OR: 1.22, p = 0.018). For intertrochanteric fractures alone, a wider NSA (OR 1.27, p = 0.033) and larger HO (OR 1.29, p = 0.036) increased the risk for this fracture type while a longer HAL was protective (OR 0.85, p = 0.30). Other recorded parameters revealed no correlation. CONCLUSION: Results show that hip geometry plays a role in the risk and incidence of developing femoral neck or intertrochanteric fractures. These measurements may aid in identification of patients at risk for fractures, act as a guide for implant design, and increase accuracy of hip reconstruction among the elderly population.

Purpose: Blood loss during and following elective total hip arthroplasty (THA) can be substantial and may require allogeneic blood transfusions which carries significant risks and morbidity for patients. Intraoperative use of tranexamic acid (TXA) has been proven to reduce the need for allogeneic blood transfusion in elective THA patients. Data regarding TXA efficacy in reducing blood loss in trauma patients undergoing non-elective primary THA is sparse, and its routine use is not well established. Methods: This is a retrospective analysis of a consecutive cohort of patients who underwent non-elective primary THA in a tertiary medical center between January 1st 2011- December 31st 2019. The cohort was divided into two groups; one received perioperative TXA treatment while the other did not. Blood loss, blood product administration, peri and postoperative complications, readmissions and 1-year mortality were compared between groups. Results: A total of 419 patients (146 males, 273 females) who underwent THA were included in this study. The "TXA" group consisted 315 patients compared to 104 patients in the "no TXA" group. TXA use reduced postoperative bleeding, as indicated by changes in hemoglobin levels before and after surgery (Hb= -2.75 gr/dL vs. Hb= -3.34 gr/dL, p<0.001) and by administration of allogeneic blood transfusions (7.0% vs. 16.3%, p = 0.004). Conclusion: Similar to the known effect of TXA in elective THA patients, the use of TXA treatment in patients undergoing non-elective THA led to a significant reduction in postoperative blood loss and in the proportion of patients requiring allogeneic blood transfusions.

Introduction: Use of ceramic bearings in total hip replacement is increasing, especially in younger patients but there are still reports of Ceramic failures and dealing with the revision surgeries in these cases is challenging. Material and Methods: We present our experience of 10 hips (9 patients) who underwent revision for ceramic failures between 2008-2012.Seven patients reported squeaking. There were 8 head and 3 ceramic liner fractures. Seven patients had a small head (28mm) with short neck. All patients had revision with titanium sleeve with ceramic bearing with revision of the socket to a uncemented cup. One patient was lost to follow up and 1 deceased. Eight hips (7 patients) were followed up clinically and radiologically. Post-operative Oxford Hip Scores were obtained, and the radiographs were accessed for osteolysis, loosening, subsidence and osteo-integration. Results: All patients had good to excellent function and Oxford Hip Score except one patient who had periprosthetic fracture and regained the function after the healing of the fracture. There were no Re-revisions for bearing wear, osteolysis. Radiological follow up did not show any osteolysis or loosening in any of the hips. Discussion: There are limited follow up results of revision hips following ceramic failures. Our Study highlights the importance of early diagnosis, prompt surgery with extensive debridement and use of appropriate titanium sleeve with revised ceramic bearing couple can yield satisfactory mid-term results. Conclusions: Our study shows good clinical and radiological mid-term results of ceramic failure revision hip replacements.

42 years old hunter with no previous medical history was shotgunned.
Following injuries were diagnosed during the primary survey: comminuted trochanteric and femoral neck fracture, femoral and ischiadic nerve palsy.
As part of damage controll surgery, debridement, PMMA chain insertion and extrafocal fixation were perfomed.
Primary the wound treated by delayed skin closure and later the healing was supported by NPWT therapy. After six weeks the ex-fix was removed and antibiotic spacer was inserted. Primary wound healing occured without any signs of infection. The neurological recovery of the extremity took almost a year. Low grade infection were excluded by serial labs and culture. Finally the patient underwent a total hip arthroplasty with good results.

Background: Meralgia Paresthetica (MP) is an uncommon condition that results from compression of the lateral femoral cutaneous nerve (LFCN), typically when it passes under the inguinal ligament. Most patients are managed conservatively, though in rare cases of severe long-lasting pain, surgical decompression or section of the nerve is required. Case Presentation: We report two cases of middle-aged female patients with no relevant medical history, presenting severe pain and numbness in the upper lateral region of the thigh. They were initially diagnosed with trochanteric bursitis and submitted to bursal infiltration and physiotherapy without any improvement of their symptoms. Both electromyographies were negative and evaluation by other medical specialities was even requested. MP diagnosis was confirmed after LFCN block with lidocain. Although temporary relief of symptoms was achieved, severe and persistent pain rendered surgical treatment necessary, with section of the LFCN and infiltration of the nerve stump with bupivacain. After a minimum follow-up of six months, aside from hyposthesia of the upper outer thigh, patients remain asymptomatic and pleased with the surgical outcome. Discussion: MP is an unusual mononeuropathy which is frequently overlooked or misdiagnosed. The symptoms include tingling, numbness and burning pain in the outer thigh. While electromyography is often inconclusive, nerve blocking is generally both diagnostic and therapeutic. It is a diagnosis of exclusion, meaning proper treatment is usually delayed. Conclusion: LFCN section is a simple, safe and efficient procedure, though it shoud only be considered as a last resort solution, regarding the expected hyposthesia in the nerve distribution area.

Total hip arthroplasty (THA) has been considered the operation of the century due to its major impact on the quality of life of those who suffer from hip arthritis. There is a growing demand for this surgery in increasingly younger populations. Therefore, it is important to closely monitor patients who undergo this surgery as there are complications that can be avoided or mitigated if diagnosed and treated early. Polyethylene liner wear is a common occurrence that can significantly reduce a THA’s lifespan. We present the case of a 65-year-old female with history of left THA five years prior with good clinical results but no further follow-up past three months postoperatively. The patient presented in our office complaining of altered gait that had persisted for months with no significant left hip pain. Upon examination, leg length discrepancy and limited range of motion were apparent. A radiograph revealed complete wear through the polyethylene liner and acetabular cup with posterosuperior subluxation and protrusion of the femoral head through the acetabular roof. Osteolysis was also evident in the proximal femur. The patient underwent revision arthroplasty soon thereafter with a cementless revision cup with autogenous bone graft and a cementless modular femoral stem after a controlled proximal femur osteotomy and osteosynthesis with a trochanteric grip plate and cable system. The polyethylene liner and titanium acetabular cup were fragmented and tissue metallosis was evident. Intraoperative cultures were negative. The patient recovered uneventfully and at 2-year follow up was pain-free and had returned previous activity.

Nowadays, primary tuberculous bursitis is considered a rare condition, accounting for 1-2% of all musculoskeletal tuberculosis.
A 50-year-old woman was referred to our department to investigate a persistent pain in her left hip with 6 months duration. She was afebrile but presented with diffuse swelling from the buttock through the thigh, but no sign of acute inflammation such as heat and redness.
Imaging showed a partial destruction of the margin of the greater trochanter, lytic foci in the underlying bone and a small focus of calcification in the adjacent soft tissues and a mass in relationship with the trochanter. A needle biopsy revealed granulomatous tissue. The patient underwent complete excision of the bursa and curettage of the surface of the trochanter. Mycobacterium tuberculosis was isolated and definitive diagnosis of tuberculous bursitis was made. The patient completed a treatment with rifampicin and etambutol for 6 months. There has been a complete resolution of the symptoms after 3 months and no recurrence after 4 years of follow-up. On plain radiograph the remodeling of the bone structure is clearly visible.
Discussion /Conclusion
The rarity of tuberculosis in the region leads orthopedic surgeons to neglect this potential diagnosis, resulting in a delayed treatment. The pathogenesis of tuberculosis of the greater trochanteric area has not been well defined. Both hematogenous infection and propagation from other locations are reasonable explanations. Surgical intervention is mandatory for cure and the use of several antituberculosis agents is a standard approach.

Background: Surgical management of long bone segmental defects is a challenging dilemma. One option is the Masquelet procedure which uses autologous bone graft (BG). Recently, the use of a reamer, irrigator, aspirator (RIA) system has gained popularity for harvesting BG but raises concerns related to increased intramedullary pressure (IMP) and potentially fatal fat embolism syndrome (FES). Case Presentation: An otherwise healthy 37-year-old black man presented to our Institution with non-union after treatment with ORIF for a femoral shaft fracture and subsequently removal of the hardware. The Masquelet technique was used, this included sequentially reaming of both femurs using the RIA system. During this process, the patient developed respiratory distress and neurological deterioration. Results of a CT scan revealed a pulmonary embolism. The patient received standard anticoagulation treatment and began to steadily improve his medical condition. Discussion: The RIA was used for IM canal preparation, debulking of possibly infected tissue in the non-united femur, and BG harvest of the contralateral femur. Although it is likely that the segmental bone loss allowed the non-union femur to ‘‘vent’’ the IMP, the intact femur was the most likely cause of the increased pressure and embolic event. The speed, the forward pressure, loss of water flow or clogging of the reamer head or flutes are factors that increase IMP. We reported a case of fat PE in an otherwise healthy patient that suggests that multiple long bone reaming may be a risk factor for FES even when new and safer systems are used.

Background: Femoral head fractures (FHFs) are considered uncommon injuries. Open reduction and internal fixation (ORIF) is preferred for most displaced fractures. Several surgical approaches had been utilized with controversial results; Surgical hip dislocation (SHD) is among these approaches. The aim of this systematic review was to evaluate the results of utilizing SHD in the management of FHFs. Methods: Major databases including PubMed, Embase, Web of Science and CENTRAL were searched to identify studies reporting on outcomes of SHD in treatment of FHFs. We extracted data on functional outcome, postoperative complications, reoperation rate, operation time, and blood loss. We calculated the mean differences (MDs) for continuous data with 95% confidence intervals (CIs) for each outcome and the odds ratio with 95% confidence intervals (CIs) for binary outcomes. P < 0.05 was considered significant. Results: Nine studies met our inclusion criteria, total of 104 patients. SHD resulted in a satisfactory clinical outcome in 85% patients with 74% achieved anatomic reduction. Overall complication rate ranged from 30% to 86% with osteonecrosis of femoral head, heterotopic ossification, and osteoarthritis being the most common complications. Nearly, 20/104 patients underwent revision surgery with 14 patients required conversion into total hip arthroplasty. The average operation time was 123.74 minutes, while the average blood loss was 491.89 ml. Conclusion: SHD is considered as a safe and effective approach for management of FHF, however, the surgeon should be familiar with this approach.

Background: Insufficiency fracture of bilateral neck of femur, simultaneously, is very rare. Insufficiency fractures are generally undisplaced.We present a rare case, of Insufficiency fracture of bilateral neck of femur with coxa vara in a young female Method: A 24 year female presented with inability to walk from one week and history of groin pain since last three months, even when patient was pain free she used to walk with waddling type gait. There was no history of trauma. On radiological examination, completely displaced neck of femur fracture was identified with coxa vara on left side (Fullerton & Snowdy type III ) and undisplaced tension side fracture on right side (Fullerton & Snowdy type II ).On laboratory workup, serum vitamin D level was 11nmol/lt ( range 75-250), calcium level was 8.0mg/dl ( range 8.8-10.6), parathyroid hormone level was 200pg/ml(range 18-85), phosphorus level was 2mg/dl(range 2.4-4.4). Other lab investigations, endocrinological profile and rheumatological profile were normal. Her bone mineral density test from lumbar spine was done after fixation of fractures and her T score was – 2.0.Patient was planned for valgus intertrochanteric osteotomy and fixation by dynamic condylar screw with a prebend plate. She also received an intramuscular does of 6lakh IU vitamin D and oral dose of 60,000 IU vitamin D every week. Result: On six month follow up both side fractures were well united and patient was able to walk without pain, with full weight bearing and normal gait .Her lab investigations also returned to normal during follow up.

Background: Dislocation after total hip arthroplasty (THA) is a frequent complication of the posterolateral approach, varying its incidence between 0.5 to 10% in primary THA. It is the second cause of THA revision, just after aseptic detachment.

Objectives: The purpose of this study is to evaluate the dislocation rate after THA with the absence of repair of the joint capsule and external rotators, in the patients operated in our hospital.

Study Design & Methods: Through a retrospective analysis of patients submitted to THA between January 2015 and December 2016, with at least 2 years of follow-up, the following data were collected from 368 patients: age, gender, pathological history, reason for surgery, femoral head size and number of episodes of dislocation. All surgeries were performed using a hip posterolateral approach, without suturing the joint capsule or external rotators.

Results: 372 patients were analyzed, with an average age of 64.8 years, 52% of whom were male. The main cause of THA was primary coxarthrosis (83%) and the type of THA most often performed was cementless (83%). Thirteen (3.5%) patients presented episodes of dislocation, with early and late dislocation in 2.4% and 1.1% of patients, respectively.

Conclusions: The dislocation rate after THA obtained in our hospital is within the interval cited by the literature. The absence of repair of the joint capsule and external rotators, besides reducing surgical time, decreases blood loss. The prevention of dislocation should continue to depend on careful pre-surgical planning and rigor in surgical technique.

Introduction: Cemented total hip endoprosthesis Link Lubinus SP II has been used for decades with excellent results in arthroplasty registries, but surgeon-stratified reports of endoprosthetic survival are very rare. The aim of the presented single-hospital cohort analysis of this implant was to determine Link Lubinus SP II survival rates 10/15/20/25/30 years after the primary implantation and to find out whether endoprosthesis survival depended on patients’ age, gender, operated side, operating surgeon and the season of the year. Methods: The study included 2943 consecutive primary Link Lubinus SP II hip endoprostheses implanted at the University Medical Centre Ljubljana, Department of Orthopaedic Surgery (Ljubljana, Slovenia) between January 1, 1985 and December 31, 2018. Kaplan-Meier analysis and Cox regression were performed after minimum 2 and maximum 30 years of follow-up. Results: At 10/15/20/25/30 years after implantation, the estimated cumulative proportion of revision-free surviving Link Lubinus SP II total hip endoprostheses was 94/90/88/87/87 % and the cumulative proportion with unremoved immobile components was 96/93/90/89/89 %, respectively. After adjustment for age, gender and operated side, particular surgeons (odds ratios 3.94-4.74) and season of the year at primary implantation (spring vs. winter odds ratio 1.87) were statistically significant risk factors of worse implant survival. Conclusion: The study presents the largest published Link Lubinus SP II total hip arthroplasty cohort from a single non-developmental hospital with 26981 component-years of observation. Study results highlight the impact of environmental climatic factors and variability between surgeons on the long-term implant survival.

Introduction: A barbed suture is a self-anchoring knotless suture hypothesized to shorten suture time and reduce the tension point of the wound. We compare the barbed suture and the interrupted suture for fascial closure in total hip arthroplasty. Methods: A retrospective study for patients who underwent total hip arthroplasty by a single surgeon from March 2014 to June 2020 was performed. We evaluated 324 cases among 274 patients consisting of 188 males and 86 females. The following data were collected from the medical record: patient demographics, time for wound closure, the number of threads used, hemoglobin level, visual analogue scale for surgical site pain, and wound complications. Variables were analyzed for association with closure time using multiple regression analyses between the group with the barbed suture(the SFX group) and with the interrupted suture(the Vicryl group). Results: Mean closure time was 5.8 minutes lower in the SFX group versus the Vicryl group(P < 0.01). The mean number of #2 Vicryl sutures used for closure was 2.2 lower in the SFX group versus the Vicryl group(P < 0.01). There were no statistical intergroup differences in the mean largest hemoglobin drop, the incidence of transfusion, and surgical site pain. There were 4 cases with wound complications: 1 in the SFX group and 3 in the Vicryl group, which showed no statistical difference(P = 1.00). Conclusions: The use of barbed sutures for fascial closure in THA effectively reduces the surgical time as well as the number of threads without increasing the wound complications.

Introduction: Hip fractures in the elderly can be a devastating event. Extracapsular fractures of the proximal femur in the geriatric population present a public health problem in terms of high morbidity and mortality. We analyze the ratio between the number of platelets and lymphocytes as a prognostic factor for the in-hospital mortality of these patients. Material and methods: We conducted a 3-year retrospective study involving 935 patients with extracapsular fractures of the proximal femur. After applying the exclusion criteria, a number of 780 patients were analyzed in terms of demographic factors, type of treatment, platelet / lymphocyte ratio and hospital mortality. The results were statistically processed using SPSS 18.0. Results: In the studied lot, we identified 35 deaths (4.5%), with a significantly higher frequency in the group of nonoperatively treated patients (19.0% vs 1.7%; p = 0.001). In the group of deceased patients, 82.9% were over 70 years old, while in the survival group the share of those over 70 years old was 76.6% (p = 0.388). The mean level of PLT / Ly # ratio was significantly higher in deceased patients (285.19 vs 197.72; p = 0.022). Conclusions: The in-hospital mortality of patients with extracapsular fractures of the proximal femur is high, the results identified being consistent with those in the literature. The increase in PLT / Ly # ratio is a predictor for in-hospital mortality of patients with extracapsular fractures of the proximal femur. Keywords: proximal femoral fractures, geriatric patients, mortality

Introduction: Use of ceramic bearings in total hip replacement is increasing, especially in younger patients but there are still reports of Ceramic failures and dealing with the revision surgeries in these cases is challenging. Material and Methods: We present our experience of 10 hips (9 patients) who underwent revision for ceramic failures between 2008-2012.Seven patients reported squeaking. There were 8 head and 3 ceramic liner fractures. Seven patients had a small head (28mm) with short neck. All patients had revision with titanium sleeve with ceramic bearing with revision of the socket to a uncemented cup. One patient was lost to follow up and 1 deceased. Eight hips (7 patients) were followed up clinically and radiologically. Post-operative Oxford Hip Scores were obtained, and the radiographs were accessed for osteolysis, loosening, subsidence and osteo-integration. Results: All patients had good to excellent function and Oxford Hip Score except one patient who had periprosthetic fracture and regained the function after the healing of the fracture. There were no Re-revisions for bearing wear, osteolysis. Radiological follow up did not show any osteolysis or loosening in any of the hips. Discussion: There are limited follow up results of revision hips following ceramic failures. Our Study highlights the importance of early diagnosis, prompt surgery with extensive debridement and use of appropriate titanium sleeve with revised ceramic bearing couple can yield satisfactory mid-term results. Conclusions: Our study shows good clinical and radiological mid-term results of ceramic failure revision hip replacements.

We studied the safety and efficacy of multimodal prophylaxis (MMP) in patients with a prior history of venous thromboembolism (VTE) undergoing primary, elective THA and TKA. MMP included preoperative discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid postoperative mobilization, pneumatic compression boots, vigorous ankle dorsiflexion during the whole recovery period, and chemoprophylaxis tailored to the patient’s VTE risk. Between 2004 and 2019, 465 patients underwent 277 THA and 188 TKR. All had a history of VTE: deep venous thrombosis (DVT) in 320 (69%), pulmonary embolism (PE) in 66 (14%), or both in 79 (17%). Postoperative chemoprophylaxis included aspirin (59; 13%), anticoagulation such as coumadin, low molecular weight heparin, or novel oral anticoagulants (360; 77%), or both aspirin and anticoagulation (45; 10%). One-year mortality and complications within 120 days including VTE, wound healing issues, bleeding and hematomas, and unplanned readmissions, were recorded. Postoperative VTE occurred in 12 patients (2.6%). Bleeding-related complications occurred in 13 patients (2.8%), including hematoma requiring evacuation or aspiration (4; 0.9%). During the first year seven patients died, including one due to PE and another due to hemorrhagic stroke while on coumadin. This study of 465 joint replacements in patients with a history of VTE, spanning 15 years, demonstrated that MMP is safe and effective in patients with a prior history of VTE. Mortality due to VTE was similar to that due to anticoagulation (0.2%). Postoperative anticoagulation should be prudent as few patients developed postoperative VTE (2.6%) while bleeding complications occurred at a similar rate (2.8%).

Hip fracture is a major public health problem in our country. It is currently agreed that hip fracture is an indicative marker of compliance of the care provided to patients with health standards and of clinical and organizational performance of the hospital.
The objective of our study was to audit the quality of care provided to patients admitted in our orthopedics and traumatology department for hip fractures.
We collected the data available in the medical files of patients admitted in our orthopedics and traumatology department for hip fractures during the year 2018. We used a sheet containing the epidemiological, clinical, surgical and follow-up data of these patients.
We collected 303 patients. They spent the average of 8.39 ± 8.43 hours in the emergency department and 8.89 ± 4.71 days in orthopedics and traumatology department before surgery. The patients were discharged from hospital after a mean duration of 10.74 ± 6.73 days. Pressure sores were observed in three patients. Nine patients had infection. Six of our patients died. All deaths occured before surgery. Seventeen patients were readmitted, five within an average of 30 days. Fourteen of these readmissions were related to hip fracture, including six for osteosynthesis-associated infection.
The assessment of hip fracture management must be continuous in order to highlight the defects and to propose solutions that should be applied and re-evaluated.

[Introduction]
Developmental dysplasia of the hip (DDH) has anatomical abnormality, which is relative contra-indication of curved short stem (CSS) in general. The purpose is to clarify whether CSS can be indicated for DDH and calcar loading of CSS can reduce stress-shielding.
[Materials and Methods]
One hundred fifty DDH patients who were underwent THA with CSS were enrolled between 2013 and 2015. There were 124 females and 26 males. The average age at operation was 64 years old. The average follow-up term was 70 months (60-84 months). Femoral bone qualities were Dorr type A in 20, B in 124 and C in 6 hips. In principle, intramedullary fitting of CSS was planned to make contact on medial calcar and lateral-proximal flare (calcar loading). Clinical hip score and radiographic performances were estimated.
[Results]
Preoperative and the last follow-up hip score were respectively 45.7 and 94.5 points. Any radiolucent lines were not seen on the porous surface of stem. Cortical hypertrophy was observed in only 2.6 %. Spot welds were observed at the zone 3, 5, 6, 10 and 12 in over 95 %, and at the zone 7 in over 50 %. Stress shielding were judged as none in 16 %, the 1st stage in 72 %, 2nd in 12 % and 3rd and over in 0%. Periprosthetic fracture, stem loosening and revision were not experienced.
[Discussions]
CSS could be indicated even for DDH patients, followed by good bony ingrown fixation. Decreased stress shielding might be induced by calcar loading with CSS.

Management for femoral neck fractures are multifactorial; however, in the young active adult, the goal is to preserve the femoral head, avoid osteonecrosis, and achieve union. Good visualization of the fracture is needed to achieve anatomic reduction to improve outcome. From June 2018 to December 2020, eight patients aged 26-53 years old, diagnosed with displaced intracapsular femoral neck fractures were operated between 4 and 28 days from injury. Open reduction was done using the Smith-Peterson Approach. After reduction, a pin was inserted from the greater trochanter to the femoral head to the acetabulum, to stabilize the fracture fragments and prevent rotation. A separate lateral incision was made to fix the fracture using a Dynamic Hip Screw. Post-operatively, measurement of the Garden Alignment Index ranged from 160°–174° in the anteroposterior radiograph, and 174°–180° in the lateral radiograph. Average surgical time was 2 hours. Functional outcome of the patients was evaluated using Harris Hip Score (HHS) at 6-12 months post-operatively wherein four patients scored Excellent, two patients scored Good and one patient scored Fair. Non-union was not observed and one patient had stage II avascular necrosis of the femoral head but is ambulatory with Good HHS and without any assistive device. Thus, Smith-Peterson Approach creates a larger surgical site exposure and allows direct access to the femoral neck for better visualization and easier reduction, as compared to Watson-Jones Approach. Through the Smith-Peterson Approach, a more anatomic reduction and stable fixation can be achieved that promotes earlier return to function.