Purpose: The primary goal of this study was to assess the risk of postoperative surgical and medical complications among nonagenarian patients following total hip arthroplasty (THA).

Methods: Data from a high-volume arthroplasty clinic were collected to evaluate postoperative morbidity and complication rates after THA in nonagenarians, compared with a control group of younger, but similar patient group. Outcomes evaluated included length of stay, transfusion rate, and postoperative medical and surgical complication rates.

Results: A total of 97 nonagenarian patients (mean age 91.4 years) were included, and compared with 89 controls (mean age 70.2 years). Patients underwent primary or revision THA. Nonagenarian patients had significantly longer length of stay (11.4 vs. 7.98 days, p < 0.01), significantly higher risk of needing a transfusion (11.3 %vs. 3.4 % p = 0.04), and significantly higher risk of a postoperative medical complication (28.9 % vs. 11.2 % p = 0.03). There was no difference in postoperative surgical complication rate (7.2 % vs. 2.2 % p = 0.12).

Conclusion: Nonagenarian patients, when compared to a younger control group, experience significantly longer hospital stays, and risk of non-surgical complications. Arthroplasty in nonagenarian patients carries a high risk of complications, and thus careful pre-operative evaluation and the care of these patients at high volume, specialized clinics is important to optimize outcomes.

Purpose: Acoustic analysis has recently been applied to cementless total hip arthroplasty (THA). The aim of this study was to develop a machine learning algorithm to predict post-operative subsidence with high accuracy. Methods: The acoustic parameters of the hammering sounds during a broaching procedure for 62 hips in 55 patients who underwent THAs with cementless taper-wedged stem were analyzed. The patient’s basic background such as age, sex, height, weight, and body mass index, the femoral morphological parameters, and the hammering sound characteristics of 24 features of normalized sound pressure (nSP) in 24 frequency ranges were applied to binary classification using a support vector machine using the following models with different features; Model; A: nSP only, Model B; nSP + patients’ basic background features, Model C: nSP + patients’ basic background features + femoral morphological parameters. Results: In 62 hips with 310 hammering sounds, 12 hips (19.4%) showed ≥3 mm of post-operative subsidence; hence, 60 hammering sounds were set as positive examples and 250 hammering sounds were set as negative examples. The AUC was very high in all models. The accuracy (AUC/sensitivity/specificity/positive predictive value/negative predictive value/accuracy rate) of each model was as follows: Model A, 0.963/0.656/0.996/0.980/0.925/0.934; Model B, 0.9866/0.675/1.000/1.000/0.928/0.937; and Model C, 0.998/0.750/1.000/1.000/0.950/0.957. Conclusion:
In this study, we developed a high-accuracy machine learning algorithm for post-operative subsidence using acoustic parameters and additional pre-operative features. Our results represent a step toward the realisation of acoustic monitoring to avoid the complication in cementless THA.

Background; No consensus exists regarding suitable patient demographics or comorbidities for same day discharge (SDD) after total hip and knee arthroplasty (THA and TKA).

Objectives; Identify patient and surgical variables that predict SDD failure.

Methods; We conducted a population-based, retrospective cohort study of primary THAs and TKAs in Ontario, Canada from 2016-2022. Our primary outcome was length of stay. Inclusion criteria included all surgeons, THA approaches and hospitals. We excluded revision arthroplasties.

Multiple covariates were analysed including preoperative Charlson Comorbidity Index (PCCI), ED visit within 30 days, obesity, gender, ACG frailty and surgical complications. Between group statistical analysis utilised the Chi-squared test with p<0.05.

Results; 3,374 THA patients underwent SDD. 2981 (88.4%) were successful and 393 (11.6%) failed. Positive predictors for failure were PCCI, obesity, female gender, ACG frailty, hypertension, general anaesthetic and surgical complications (p<0.05 for all). Conversely, ED visit within 30 days predicted successful SDD (p<0.001).

2776 TKA patients had SDD. 2462 (88.7%) were successful and 314 (11.3%) failed. The same positive predictors were noted (p<0.05 for all) except hypertension, obesity and surgical complications.

Conclusions; Female gender, obesity and hypertension predicting failed SDD has previously been reported. Our findings of higher PCCI and ACG scores predicting failure correlates with existing research of higher ASA grades. Surgical complications and general anaesthetic delayed discharge presumably from poor rehabilitation. Increased ED admission after successful SDD suggests a failure to detect complications. Our data may be utilised to develop preoperative scoring systems that predict failure of SDD which could be applied clinically.

Purpose: The purpose of this systematic review and meta-analysis was to evaluate the joint awareness in total hip arthroplasty (THA) operated through the direct anterior approach (DAA) vs. posterior approach (PA). It was hypothesized that patients operated on through DAA had better forgetfulness of the artificial joint. Methods: A search of major literature databases and bibliographic details revealed 234 studies evaluating forgotten joint score (FJS-12) in THA patients operated through DAA and PA. Seven studies were found to be suitable for review. The risk of bias and quality of evidence was evaluated using the Newcastle-Ottawa Scale. The FJS-12 was assessed at three months, one year, and > 2 years.
Results: The mean FJS-12 at > 2 years was 82.03 in the DAA group and 80.32 in the PA group. The forest plot analysis (n=819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI: [-1.17, 5.42], p=0.21; I2=60%). However, the joint perception was significantly lesser in the DAA group at three months (MD 12.56, 95% CI: [9.58, 15.54], p<0.00001, I2=0%) and one year (MD 9.55, 95% CI: [7.85, 11.24], p<0.0001, I2=0%). Conclusions: THA patients operated on through DAA have significantly lesser joint awareness than PA in the first year of surgery. However, there is no such difference in joint perception between these two approaches after two years.

Background: The SPAIRE approach is a modification to posterior approach (PA) that preserves The Quadriceps Coxae. It aims at addressing the higher rate of dislocation and slower recovery of PA compared to the direct anterior approach. The Clinical outcomes and the learning curve have not been previously reported. Methods: All consecutive primary total hip replacements THR in a single surgeon practice across 2 sites between 6/2018 and 9/2020 were reviewed. Any THR requiring acetabular or femoral bony reconstruction was excluded. The outcome measures were dislocation, revision, and hospital stay. Minimum follow up was 1 year. Results: 401 THRs were identified. 245 were performed through SPAIRE, 29 through Pyriformis preserving PP and 127 through a PA. Mean age, ASA, and BMI are presented. No dislocations occurred in SPAIRE or PP group. 1 dislocation occurred in Posterior group. The overall revision rate was 1.2% (5patients). 3 revisions were observed in SPAIRE group, one for infection and two for periprosthetic fractures (3/245). 2 revisions for infection occurred in PA group (2/127). There was a statistically significant difference in hospital stay in favour of SPAIRE approach compared to PA. Within the first 3 months of adapting the modification, 49 % of THRs were done using SPAIRE increasing to 95 % within 6 months. Conclusion: The SPAIRE approach results in an earlier discharge compared to PA. The learning curve is not steep with no increased risk of complications. The effect on dislocation rate is hard to prove outside registry data given how uncommon it is.

Introduction
Direct anterior approach (DAA) arthroplasty has generated great interest because of its minimally invasive and muscle sparing nature. Obese patients are reported to be associated with greater incidence of complications in primary joint replacement.

Aim:
The purpose of this study was to compare patient outcomes and complication rates between obese and non-obese patients undergoing primary total hip arthroplasty (THA) through a Bikini direct anterior incision.

Methods:
This retrospective, single surgeon study compared the outcome of 258 obese patients and 200 non-obese patients undergoing DAA THA using a Bikini incision, over a 5-year period. The average follow-up was 3.2 years (range 1.1-5.6 years).

Results:
There was no statistically significant differences in the complication rate between the two groups. The obese group recorded 2 major (venous thromboembolism and peri-prosthetic fracture) and 2 minor complications (superficial wound infection), compared with the non-obese group, which recorded 2 major (deep-wound infection and peri-prosthetic fracture) and 1 minor complication (superficial wound infection). Patient-reported outcomes (WOMAC and Harris Hip Scores) showed significant post-operative improvements (p < 0.001) and did not differ between the two groups.

Conclusions:
Bikini DDA THA does not increase the complication rate in obese patients and offers similar clinical improvements compared to non-obese patients.

Introduction: Posterior dislocation of prosthetic hip is one of the disastrous complications of total hip arthroplasty
(THA) done by posterior approach. We did a novel modification of Ranawat’s technique of two-hole technique by using four suture threads of Ethibond (Polybutylate-coated Braided Polyester sutures) No. 5. Material and Methods: The method was used in cases of uncemented THA. In all the cases, we took 4 bites- two through external rotators and two through joint capsule. The upper and lower sets of threads (4 each) were passed through the corresponding drill holes made by 3.5 mm K wire. This was done by shuttling the threads by an Ehibond No. 5 needle used in the procedure previously after straightening it. The threads corresponding to capsule were tied first followed by those from external rotators. Assessment of proper approximation of capsule and rotators was done. Results: The method was used in 33 consecutive primary uncemented THA (30 patients). In 16 hips, owing to more than 2 cms lengthening, we were unable to do complete approximation. In one of the ankylosed hips, soft tissues were not strong enough to withstand the bites of suture threads. Complete approximation was achieved in 12 hips out of 16 where lengthening was less than 2 cms. Sciatic nerve palsy which recovered within 6 months was seen in one case. No case of dislocation was seen. Conclusion: Our Ranawat's procedure modification by using Ethibond is a safe method and prevents dislocation. However, long term studies based on MRI is required.

Introduction: Adequate exposure of the acetabulum is one of the cornerstones of a successful total hip arthroplasty (THA). Inadequate exposure may lead to inadequate or eccentric reaming, which may jeopardize proper acetabular component positioning and eventual aseptic loosening in future. Methods: We assessed the applicability of a novel method of acetabular exposure by controlled release of soft tissues followed by placement of pin retractors at 12 and 3’o clock (Right hip) or 9’o clock (Left hip) and placement of Cobra retractors at remaining two positions in patients undergoing THAs. Any intraoperative or post-operative complications were also noted. Results: The method was used in 50 consecutive primary uncemented THAs in 43 patients at our institute. The various primary etiologies were avascular necrosis of hip(n=16), ankylosing spondylitis(n=18), other inflammatory arthropathies(n=10), failed Austin Moore prosthesis hemiarthroplasty(n=2), dysplastic hip(n=1), and femoral neck fracture(n=3). In-situ osteotomy was done for 10 hips: (7 for ankylosed hips and 3 for protrusio acetabuli). We were able to achieve the desired 360 degrees exposure in all hips. Intraoperative complications were partial breakage of the anterior wall in one case and over-reaming of posterior wall in 3 cases. Postoperatively, we encountered anterior groin pain which resolved with analgesics and a Sciatic nerve neuropraxia which recovered over next 6 months in one patient each. Conclusion: Based on our short-term pilot study, controlled soft-tissues release followed by placement of retractors at 3,6, 9 and 12 o’clock positions is an easy and reproducible method for achieving 360 degrees acetabular exposure.

Introduction: cemented Dual Mobility (DM) cups have traditionally been used with Kerboul Cross (KC) plates and bone graft for acetabular reconstruction. In this study the DM cups were inserted on top of Tantalum Augments (TA) to reconstruct acetabular defects Paprosky type III that may be difficult to successfully reconstruct by the traditional techniques. Methods: 23 acetabulae were reconstructed using the combination of TA, bone graft and cemented DM cups. These patients were prospectively evaluated radiologically and clinically using the modified Harris Hip Score (HHS). Indications for revision THA were infection, aseptic loosening and dislocation. 2 patients died leaving 21 patients for the final review with minimum 2 years follow up. 6 patients had 2 TA augments in the reconstruction while 15 had only one TA per acetabulum. Results: at a mean follow up of 56 months (range 24-84 months) none of these hips was revised or awaiting revision. TA augments are well supported and incorporated with no evidence of loosening or bone lysis. The HHS has improved from 32 +/- 10 pre to 87 +/- 5 post (P< 0.0001). Conclusion: Revision of massive acetabular defects carries a high risk of postoperative instability and would benefit from using a DM implant. TA is a game changer in providing support to cemented cups. The combination of TA and cemented DM cups has an encouraging medium term outcome that supports its continued use. Longer term results are to be seen.

Objectives: We aimed to evaluate the difference between right- and left-side acetabular cup placement during primary THA by a right-handed surgeon operating through a direct lateral approach and using manual instruments. Methods: A retrospective evaluation of the last 400 THAs performed by a senior right-handed arthroplasty consultant, who operated through a direct lateral approach in a lateral decubitus position using manual instruments, with the aim of positioning cups within the Lewinek safe zone. After excluding revision THAs, complex primary THAs, and bad-quality radiographs, 224 THA [117 left (group Ⅰ) and 107 right (group Ⅱ)] radiographs were included. Cup inclination angle and anteversion were evaluated on plain AP pelvis radiographs. Results: There were no significant differences regarding gender, diagnosis, and cup fixation (49.1% cemented cups vs. 50.9% cementless). The mean inclination angle in group Ⅰ and group Ⅱ was 37.9°± 5.6 and 39.4°±5.5, respectively, and the difference was significant,p<0.05. The mean anteversion was 24.3±6.2° for group Ⅰ, and 21 ± 6.4° for group Ⅱ p<0.05. 90.6% and 95.3% of the cups were within the safe zone for abduction in group Ⅰ and group Ⅱ, respectively. While for anteversion, 65% and 54% of the cups were within the safe zone for group Ⅰ and group Ⅱ, respectively. No difference was found regarding cup position related to the type of fixation. Conclusion: Cup positioning in the left or right hip seems to be affected by the surgeon’s handedness, even in the hand of an experienced surgeon. Further correlation to functional outcomes is mandatory

Purposes: COVID-19 Outbreak made patients underwent hip arthroscopy for femoracetabular impingement not able to undergo proper rehabilitative protocols. The study aimed to evaluate impact of a home-based exercises rehabilitation protocol for those patients and compare it to the routine physiotherapy protocol and evaluate impact of COVID-19 restrictions on rehabilitation and outcomes. Methods: Prospective study with retrospective cohort arm design. Patients who underwent arthroscopic management of femoracetabular impingement during the study period from May 2020 to May 2022 included with 1 year follow up, 24 patients were taken as pandemic group. From existing databases from June 2018 to June 2020 with 1 year follow up, 30 patients underwent arthroscopic management of femoracetabular impingement were included as cohort pre-pandemic group. Patients demographic and baseline data, Modified Harris Hip Score (mHHS) and international Hip Outcome Tool-12 Score, surgical satisfaction questionnaire and COVID-19 rehabilitation questionnaire were used for data collection. Home based-exercises (teaching booklet) was disseminating to pandemic group. Results: no statistical significant difference (p = 0.059) between cohort pre-pandemic (79.53±7.25) and pandemic (75.73±7.43) groups regarding preoperative mHHS. international Hip Outcome Tool-12 score was significantly improved in pandemic group compared to cohort pre-pandemic group at 6 and 12 months (72±22.33, 80.85±13.46 versus 58.03±23.89, 62.1±19.52, p = 0.029, p <0. 001, respectively). All patients of pandemic group (100%) reported that their recovery limited due to COVID-19 pandemic. Conclusion: patients underwent surgeries during COVID-19 pandemic felt that their recovery limited due to restrictions of COVID-19. However, those patients significantly had better outcomes than cohort pre-pandemic group.

Total hip prosthesis in ankylosis of the hip is currently an integral part of the therapeutic arsenal. Conversion of ankylosed hips to prostheses remains a very difficult procedure, although several reports have demonstrated excellent survival with high patient satisfaction. Preoperative planning is essential.
We present a prospective study of 36 patients,72 total hip prostheses performed on ankylosed hips.
They were 29 men and 7 women with an average age of 32 years. Ankylosis of the hip was bilateral in 82% of cases, fusion was spontaneous in all patients and ankylosing spondylitis was the etiology par excellence. The muscle involvement of the gluteus medius was present in 100% of patients with an average score of 2.
All patients underwent simultaneous bilateral arthroplasty. Spinal anesthesia was used only 8 times, general anesthesia was used in the others with intubation difficulties
The THAs were uncemented in 84% of cases with a dual mobility acetabulum in 34 patients. the Postel Merl d'Aubigné score went from an average of 6.3 preoperatively to 15.2 postoperatively.
the total hip prosthesis has been recommended to reduce the excessive stress on the neighboring joints and stop the degenerative process at their level. However, replacing an ankylosed hip with a total hip prosthesis is a real problem.This arthroplasty has improved the quality of life of patients, for whom even incomplete functional recovery allows them to regain socio-professional development close to normal.For this surgery to be effective, multidisciplinary care with good collaboration between surgeon, rheumatologist and physiotherapist is necessary.

Introduction: The "gold standard" of treatment remains two-stage revision hip arthroplasty (RHA). However, the frequency of recurrent infection can reach up to 33%. The examination for PJI between stages is still discussable, especially with spacers. Objective: was to evaluate the effectiveness of diagnostic algorithm examination in patients with PJI before the 2nd stage of RHA. Material and methods: We evaluate the patients in 2 groups, 40 patients were in each. The 1st was with a diagnostic algorithm? Which include ESR, CRP, aspiration tests and alpha -defensin test. The second group was only with ESR, CRP. The main criteria was to find PJI in each group by M.B. Coventry и D.T. Tsukayama type 4 and recurrent PJI after RHA. The aspiration test was effective in 75 %, but in 25% it was “dry tap”. Results: In the 1st were 11 (30,5%) patients with type 4, but in standard group microbes were isolated in 25 (69.4%). According to our data the Synovasure® Alpha Defensin Test was effective in 47 cases (78%), non-effective in 13 (22%) cases. After one year follow-up was 1 (2,%%) case of recurrent infection in the 1st group. In the 2d group were 8 (20%) recurrent PJI. Conclusion: it is necessary to aspirate all patients with spacers. Successful aspiration lowers the risk of PJI type 4 by 2.27 times (from 69.4% to 30.5%). Diagnostic algorithm utilization lowered the risk of recurrent PJI by 8 times (2.5% in the 1st group vs 20% in the 2d group) (р < 0,01).