Backround: The C-stem polished triple-tapered femoral implant was designed to load the femur more physiologically, thus avoiding negative bone remodelling in the form of stress shielding, calcar resorption and the development of distal femoral cortical hypertrophy. The aim of this ongoing prospective study was to assess the complication rates and long-term outcome of the use of the cemented C-Stem polished triple tapered femoral component. Methods: Data was collected prospectively on 500 consecutive C-stem femoral implants in 455 patients between March 2000 and December 2005. A posterior approach was used in all cases, with a cemented UHMWP acetabular component. Canal restrictors, stem centralisers and Palacos-R cement with Gentamicin were used in all cases. All patients had annual clinical and radiological review for the first 5 years then alternate yearly thereafter. Results: 214 patients died, 12 moved out of region and 7 were lost to follow-up. There were 7 periprosthetic fractures and 13 dislocations. 16 acetabular components were revised for aseptic loosening, with 15 currently loose, all of which are associated with rapid wear. At 10 years, loss of calcar height occurred in 4.6%, with localised lysis or demarcation in 9%. Seven femoral implants loosened aseptically (1.4%), all of which were associated with rapid wear of the acetabulum. Conclusion: The C-stem implant has performed well, with low complication and re-operation rates. Implant failure in cemented hip replacement, on both the femoral and acetabular sides, and negative bone remodelling in the calcar region are still related to high wear rates.

Introduction: Postoperative heterotopic ossification (HO) is the presence of bone formation surrounding the hip region following total hip arthroplasty (THA). Currently, risk factors such as different surgical approaches are not established and lack consensus in the reported literature. We sought to systematically review the literature reporting on HO in relation to operative approaches to identify if any clear trends in the literature exist. Methods: A literature search via Medline (PubMed), EMBASE, and Cochrane databases was performed. Peer-reviewed articles were identified that reported on HO following THA. Studies were required to report surgical approach (e.g. direct anterior, anterolateral, posterior) and either Brooker, Arcq or deLee HO scores. Results: A total of eight studies analyzed the rate of HO stratified by surgical approach after THA. Two studies demonstrated statistical significance in showing that patients treated with DAA were the least likely to develop clinically significant HO. Three studies demonstrated that the lateral or anterolateral approach was a statistically significant independent risk factor for the development of HO. Finally, three studies lacked clear statistical significance between surgical approaches. Conclusion: Patients who undergo THA via DAA are less likely to develop surgical site HO and patients who undergo THA via a lateral or anterolateral approach are more likely to develop HO. Future studies are warranted on HO development of multiple surgical approaches, ideally from the perspective of a single surgeon experience to control for many confounding variables.

Introduction: Varus alignment of femoral components has been linked to loosening and failure of cemented composite beam implants. There have been no published results detailing the long-term effect of placement in varus alignment on taper-slip stems. Methods: We prospectively analysed the results of 500 consecutive C-Stem implants between March 2000 and December 2005. Patients were followed up annually for five years and alternate yearly thereafter. Results: 107 femoral components (21.4%) were implanted in 5 degrees or more of varus with respect to the long axis of the femur, and 47 in 5 degrees or more of valgus (9.4%). Alignment within 5 degrees of neutral was achieved in 346 cases (69.2%). In the varus group there were 5 dislocations, and one periprosthetic fracture treated by ORIF. No femoral components have aseptically loosened. In the Neutral group five femoral components (1.4%) have loosened aseptically, two of which have been revised, all in hips with loose acetabula associated with high wear rates. Discussion: Varus implantation of the femoral component was more common in older (69.9 v 68.1yrs) and particularly male patients (45% v 34%). There were no differences in average femoral offset or average subsidence at 10 years in the varus group (1.45 v 1.44mm). Five femoral components (1.4%) loosened aseptically in the neutral group but none in
the varus. Conclusion: Varus implantation of a triple-tapered cemented implant was not therefore detrimental as anticipated, but in fact resulted in a lower risk of femoral loosening at 13 to 18 years of follow-up.

Aim :
This study reviewed the incidence of the limb length inequality in DGH against published evidence and identify the risk factors such as implant type, surgical approaches, use of preoperative templating, and body mass index.

Methods
A retrospective study involved 380 unilateral primary total hip replacement from June 2018 till June 2019. Data including age, gender, body mass index, operating surgeon, approach, type of fixation, prior templating, and type of anaesthesia was collected from the NJR database.
The limb length was measured radiologically both pre and postoperatively using Orthoview workstation® in terms of the vertical distance between the intra-acetabular teardrop line and the medial apex of the lesser trochanters by two authors.
338 cases were included after the exclusion of revision cases, tilted x-rays, and hip replacement for trauma patients.

Results
The mean postoperative LLI was 2.7mm with a standard deviation of 6.56mm, with only 5.3% > 15 mm that was excellent compared to mean in the literature that varies from 3 to 17mm.
Despite the apparent difference between mean LLI was 2.19 in case of prior templating compared to 3.53 in those without prior templating, there was no significant statistical relationship (p=0.06).
Similarly, with the type of anaesthesia, despite lower mean in regional anaesthesia than with general one, it wasn’t statistically significant.
Neither type of fixation nor approach showed any influence on the overall limb length balancing.
There was a weakly positive Pearson correlation between body mass index and incidence of lengthening of the limb.

The aim of this study was to evaluate any difference in mortality, morbidity and hospital stay between cemented hip hemiarthroplasty (CH) and uncemented hip hemiarthroplasty (UCH).The default implant was CH unless surgeon or anaesthetist had concern regarding cardiovascular morbidity of the patient on the day of surgery. Method:Retrospective database review of all patients who underwent hip hemiarthroplasty following displaced intracapsular neck of femur fracture in 2019. All patients were optimised before surgery. Type of implants, American Society Association (ASA) grade, hospital stay, 30-day mortality, surgical complications were assessed. Results:The cohort included 321 patients (226 CH ,95 UCH), mean age was 84 years (61-100). There were 266 (198 CH, 68 UCH) ASA 3 and 55 (28 CH, 27 UCH) ASA 4 patients. 30-day mortality was 22 (15 CH, 7 UCH) in ASA 3 and 15 (5 CH, 8 UCH) in ASA 4 patients. There was no difference in mortality between CH and UCH groups in ASA 3 and 4 patients (Chi-squared test, P=0.32). Intra-operative fractures were higher in the UCH 10(10.5%) compared to the CH group 2(0.9%). There was no difference in post-operative complications, hospital stay or dislocation.Conclusion:We found no difference in 30-day mortality, post-operative complications or hospital stay between CH and UCH, although intra-operative fracture was higher in the UCH group. Patients with cardiovascular co-morbidities can be successfully managed with CH without affecting 30-day mortality or other complications.

Background: The effectiveness of the modular junctions has been overshadowed by higher rates of mechanical failure compared to the more traditional nonmodular femoral devices. We assessed the survivorship of a modular femoral stem possessing a unique design at a minimum 10-year follow-up, with mechanical failure of the modular neck junction as the primary endpoint.
Methods: We reviewed records of 174 patients who underwent total hip arthroplasty (THA) using a modular femoral stem between 2004 – 2009. Kaplan-Meier survival analysis was used to examine mechanical failure of the modular neck and revision surgery over 10 years post-implant. Deceased subjects were censored by date of death and subjects lost to follow up were censored by their last date of contact.
Results: Kaplan-Meier survivorship analysis was conclusive of 100% survival rate with no subjects experiencing mechanical failure of the modular neck junction. Radiographic results for patients showed well-fixed modular femoral stems in all cases with no radiolucent lines around the stems. Sixty patients died of causes unrelated to their THA and 9 patients were lost to follow-up. Seventeen patients underwent interventional THA procedures during the follow-up period due to one of the following: complications associated with large-diameter metal-on-metal articulations, late joint infection, instability, and acetabular loosening.
Conclusion: Clinical and radiographic results support the use of this unique modular neck femoral component in primary THA. Results suggest that not all modular neck THA devices are equal; stem modularity does not produce unacceptable revision/failure rates in all cases.

BACKGROUND: The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients’ satisfaction. METHODS: We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients’ satisfaction were also evaluated. RESULTS: Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs 4.4, p<0.001), CCI was significantly lower (12.3 vs 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p> 0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p <0.002). CONCLUSION: Compared to the conventional inpatient care, our ERAS-outpatient protocol proved to be safer, enable faster functional recovery, and improve patients’ satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program.

Introduction: There is a gap in the literature regarding the relationship between ulcerative colitis (UC) and postoperative outcomes after primary total hip arthroplasty (THA) surgery. This study seeks to compare the minimum 2-year follow-up postoperative outcomes in THA patients with and without UC. Methods: This retrospective study analyzed the New York State’s Statewide Planning and Research Cooperative System database from 2009 to 2013 and utilized ICD9 codes to isolate primary THA patients with or without UC. A 1:1 propensity score match based on age, gender, and obesity status was performed to create two cohorts by UC status (n=207 each, 414 total). Univariate analysis was done to compare patient demographics, hospital variables and postoperative outcomes (surgical complications, medical complications, readmissions, reoperations, revisions of THA, and mortality during hospitalization). Multivariate binary logistic regression analysis controlling for age, sex, and obesity status was performed to analyze whether ulcerative colitis was a significant predictor on postoperative outcomes. Results: Age, sex, race, payment method, obesity status, and Charlson-Deyo-Comorbidity-Index were comparable between the two cohorts (all, p>0.05). Both cohorts had comparable total length of hospital stay and total surgical charges (all, p>0.05). Compared to the non-UC cohort, UC patients had comparable rates of surgical complications, medical complications, reoperation, readmission, revision of THA, and in-hospital mortality. Conclusion: This retrospective study found that in 2-year minimum follow-up THA patients, rates of adverse postoperative outcomes were comparable between the two UC cohorts. Further research is warranted to explore the relationship between UC and postoperative outcomes in patients undergoing THA.

Introduction: Prosthetic joint infection after a Total Joint Arthroplasty is a significant complication requiring prolonged management, multiple surgeries with increased mortality and morbidity in addition to cost implications. The presence of bacteriuria is perceived as one of the risk factors for post-operative prosthetic Joint infection, and the evidence is divided in establishing an association between them.
Objectives: We aim to study the association between the presence of pre-operative bacteriuria and early Prosthetic Joint infection following total hip and knee replacement.
Methods: We retrospectively reviewed all the patients who underwent total knee and hip replacements; from October 2018 to March 2019. A total of 347 patients were preoperatively screened for the presence of bacteria and cell count in the urine, and 30 [8.6%] patients were positive for bacteria in the urine identified by urine culture. We subsequently reviewed these patients postoperative for early superficial and deep infection.
Results: Escherichia coli was found to be the commonest in 72% of patients. Enterococcus faecalis, Klebsiella pneumoniae, ß haemolytic Streptococcus group B were identified in 6.8% each. Pseudomonas aeruginosa and Enterobacter cloacae were identified in one patient each. At an average 2 year follow up; none of the patients with a pre-operative positive culture for bacteria in the urine had developed early superficial or deep prosthetic Joint infection post-operatively.
Conclusions: Our study shows that there is no association and also there is no increased risk of developing early superficial or deep prosthetic joint infection in patients positive for preoperative bacterial culture in the urine.

Introduction: Urinary disorders may complicate the outcomes of total hip arthroplasty (THA) and affect the patient satisfaction. Urinary inconsistence (UI) is one the urinary disorders which has been investigated in THA patients in recent years. In the current study, the incidence of UI was investigated in the patients with end-stage hip osteoarthritis before and after THA. Materials and methods: In 2018, 400 THA patients were enrolled in the current study. Preoperatively and 6 months postoperatively, the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was completed for the patients to investigate the presence of UI. Results: The incidence of UI was 26.2% before THA which decreased to 22.5% after the operation. After THA, UI resolved in 46.7% of the patients with preoperative UI. However, there were 34 new patients with UI after the operation. UI status was the same in 79.3% of the patients. There was no statistically significant difference between the patients’ pre- and post-operative UI status (p=0.102). Conclusion: UI is an important urinary disorder in THA patients which should be examined pre and post-operatively. Although, UI dissolved in half the involved patients after the operation, however, it was developed in about 11% after the operation. More future studies are necessary to investigate the underlying mechanism.

Background: Prompt mobilisation after fracture neck of femur (NOF) surgery is one of the 6 key performance index affecting a patient’s overall functional outcome and mortality. Better control of perioperative blood pressure and renal profile following anaesthesia and surgery may impact on early post-operative mobilisation and mortality in the elderly. Aims: To evaluate the perioperative blood pressure measurements (fall of systolic BP below 90mmHg) with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. To evaluate the effect on the post-operative renal profile. Methods: 20 patients were selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts and clinical records were utilised for data collection. Results: 1 patient had a significant drop in systolic BP of less than 90mmHg (25 minutes). 1 patient in this cohort had a post-operative rise in creatinine with the rest having a negligible change in renal function. 1 patient died day 3 post-operatively, who had multiple comorbidities and active malignancy. Even with this patient, the perioperative blood pressure was well maintained and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively). Conclusion: The newer short-acting spinal anaesthesia should be used for NOF patients. It has shown to be associated with a better control of blood pressure, less adverse effects on renal function and reduced mortality. A multidisciplinary approach is essential to ensure earlier mobilisation and discharge.

Background: Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Complex revision surgery in the elderly bears substantial financial implications to the NHS and prolongs morbidity to patients. Our aim was to analyse all DHS procedures performed in our trust over nine months and compare their TAD values to the acceptable standard of ≤25mm. Methods: All patients undergoing DHS between April and December 2020 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included in the audit. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Preoperative pelvic radiographs and intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results: 122 patients were identified, three of which were excluded due to inadequate fluoroscopy. Failure was seen in 5% of the cohort (n=6), of which 5 (83%) had an unacceptable TAD. In total, 13 patients (10.9%) had TAD >25mm, of whom 8 had superiorly and 9 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had a 50% failure rate. Conclusion: This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significant posteriorly placed screws.

Introduction: It is not yet clear whether the THA undertaken for trauma setting are comparable with THA undertaken for elective setting. We conducted a prospective study to compare the
outcomes of THR for hip fractures with a best-matched elective cohort.

Method: We prospectively reviewed patients underwent THA for hip fractures from 2017 to 2019. The modified Harris Hip Score (mHHS), any further complications and death were recorded. The elective cases were matched for the month of operation, age, gender, implants, side of operation and surgeon’s grade. Unmatched cases were excluded.

Results: Forty-one matched cases were included in our study. The total modified Harris Hip Score [mHHS (total)] was significantly lower pre-operatively in elective cohort (41.4 ± 14.3 vs 60.3 ± 22.2, p<0.001) and achieved significantly higher score than trauma cohort 1-year postoperatively (88.2 ± 10.9 vs 82.6 ± 12.7, p=0.029). The trauma cohort has similar mHHS (function) pre- and postoperatively, and no significant difference was witnessed between the trauma and elective cohort postoperatively (35.1 ± 7.4 vs 37.6 ± 7.7, p=0.142). The mHHS (pain) was significantly higher in trauma cohort preoperatively (19.8 ± 15.3 vs 12.7 ± 6.3, p=0.034), but the score was significantly higher than trauma cohort 1-year postoperatively (42.7 ± 4.4 vs 40.7 ± 7.7, p=0.027). Both cohorts achieved similar complication rate.

Conclusion: With careful patient selection, hip fracture patients who received THA were able to return their pre-injured function within a year and had comparable function scores with elective
patients, and no higher complication rates.

Background: With an ageing population, FNF has become the 2nd leading cause of hospitalization in the elderly with relatively high mortality rates and disabilities. The optimal treatment of recent femoral neck fractures remains debated. Hypothesis: THA with DMC has a lower rate of dislocation and re-operation compared to bipolar HA and improve outcome. Patient and methods: a prospective cohort study conducted with displaced FNF patients over 55years in our tertiary care level 1 trauma center. 60 patients with a complete follow up for two years were included. Divided into HA-group and DMC-group. Patients were assessed for prefracture activity according Katz-ADL index and followed up for intraoperative parameters and postoperative complications including dislocation as primary outcome. The HHS was used to assess functional outcome through follow ups. Results: Mean age was 65.6±9 and 65.3±2 in HA and DMC groups respectively. There were 3 dislocations in (10%) vs 0 in DMC group with p value <0.01. intraoperative blood loss was significantly (p value 0.000) more in DMC-group 719±206 ml compared to380.6±183.8 in HA group. Mean post-op HHS at 1 year follow up for HA-group was noted to be 75.9±15.4 whereas for THA with dual mobility cup group it was 73±16.1. The difference was found to be statistically insignificant with a P-value of <0.56. Conclusion: in patients over 55 years with displaced FNF, short term observation showed that DMC can provide similar functional outcome with less dislocation rate than hemiarthroplasty. Further long-term investigations are recommended to strengthen these results. Level II evidence.

Introduction: Hip fractures, including trochanteric fractures, are among the most common types of fractures, often treated with Dynamic Hip Screw (DHS) or Cephalomedullary Hip Nail, among other fixation techniques. This study aims to explore the association of the fracture type (intertrochanteric versus subtrochanteric) with the use of mobility aids post-surgery, regardless of the fixation technique. Methods: This is a retrospective review of de-identified patients’ data from the ACS-NSQIP database. Patients aged 65 years old or above, who underwent fixation procedures for intertrochanteric or subtrochanteric fractures, using Hip Nail or DHS techniques were included. Data collected included demographics as well as preoperative and postoperative outcomes. Results: A total of 8881 patients were included and divided into two groups: 876 patients (9.9%) with subtrochanteric fractures; and 8005 patients (90.1%) with intertrochanteric fractures. No statistical significance was detected in the use of mobility aid post-operatively between the two groups. Patients who underwent surgery using DHS in the intertrochanteric fracture group were more likely to use mobility aid postoperatively compared to those with the subtrochanteric fracture group treated with the same fixation technique. Discussion: DHS was the most employed fixation technique among patients with intertrochanteric fractures. Patients who underwent surgery using DHS for intertrochanteric fractures were found to be more likely to use mobility aid postoperatively compared to those with subtrochanteric fractures treated with the same fixation technique. Conclusion: Findings suggest that mobility aid use post-surgery is independent of the type of fracture and rather potentially dependent on the fixation technique employed.

Background: Delaying surgical treatment for hip fragility fractures increases mortality, but early intervention in patients treated with direct oral anticoagulant (DOAC) may increase the risk of perioperative blood loss due to residual drug activity. This study evaluated the effect of the timing of hip fragility fractures surgeries in patients treated with DOAC. Methods: We retrospectively reviewed all records of DOAC-treated patients who underwent surgery for hip fragility fractures between 2011 and 2019. They were divided into three groups according to time to surgery since admission to the emergency room (ER), ≤24, 24-48, and ≥48 hours. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared. Results: Of the 152 suitable patients (65.7% females), 28 (18.4%) were in the ≤24-hour group, 86 (56.6%) in the 24-48-hour group, and 38 (25%) in the ≥48-hour group. Timing of surgery did not affect blood loss, as indicated by changes in pre- and postoperative hemoglobin levels (p = 0.125) and proportion of perioperatively administered packed cells (p = 0.96). There was a trend towards increased 30-day mortality in the ≥48-hour group compared to the 24-48-hour and ≤24 hour-groups (15.8%, 4.7% and 3.6% respectively. p = 0.062), and a trend towards increased 90-day mortality (7.9%, 3.5%, and 0%, respectively. p = 0.252). Conclusions: Early surgery did not increase perioperative blood loss. Delay of surgery ≥48 hours of DOAC-treated patients who underwent surgery for hip fragility fractures showed a trend towards increased 30-day mortality.

Background
The neck of femur fracture(NOFF) is commonly seen in elderly patients with multiple comorbidities. Covid infection among these puts them at higher risk of respiratory compromise and death. The aim of this study was to assess the impact of COVID-19 infection on the morbidity and mortality rates among NOFF patients.
Methods
All NOFF patients presenting from March 2020 to Dec 2020 were divided into two subgroups: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, ASA, Nottingham hip fracture score(NHFS), Charlton comorbidity index(CMI), complications, length of stay, 30-day, and 90-day mortality.
Results
Out of 273 patients included, 51 were diagnosed with the covid-19 infection. Despite no statistically significant difference between the group in terms of demographic variables, type of operation, CMI, NHFS, ASA(p>0.05); the 30 day and 90day mortality among covid patients was 35.29% and 49.01% when compared to 10.72% and 21.97% in the control group(p<0.001).33 out of 51 developed covid during the hospital stay. Length of hospital stay was significantly higher among the covid group 15.7±12.0days compared to 10.1±6.1days in the control group(p<0.001). Respiratory complications, electrolyte disturbance, AKI were higher amongst the covid group whereas no significant difference was seen in DVT, neurological or cardiac complications.
Conclusion
The patients with NOF have a high rate of 30 day and 90day mortality and complications such as bacterial pneumonia, electrolyte disturbances, and AKI when diagnosed with COVID-19 within the perioperative period with a high risk of acquiring covid during a hospital stay.