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 Hardinge approach for femoral head avascular necrosis patients.
Methods: A total of 60 patients were underwent one-stage bilateral total hip arthroplasty (BTHA). A prospective analysis of the functional outcomes and complications of one-stage BTHA through Hardinge approach in patients with femoral head avascular necrosis (AVN) performed. We evaluated all patients clinically and radiologically with serial follow-ups. A clinical hip score based upon the modified Harris Hip Score (MHHS) was performed preoperatively and again postoperatively.
Results: During period of study 44 men (73.3%) and 16 women (26.6%) with a mean age of 31.40±4.08 years (range 25 to 36 years) at the time of presentation were entered. The mean surgical time was 2.6±0.38 hrs. The mean hospital stay was 3.50±0.72 days. Hemoglobin level decreased significantly after operation, the preoperative values of 15.2 ± 3mg/dL decreased to postoperative values of 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 in patients. MHHS score improved to 95.06±3.47 in the last follow-up (P=0.0001)
Conclusion: Based the findings of current study, one-stage BTHA through Harding approach is a safe and useful treatment for patients with femoral head avascular necrosis. However, long term studies are necessary.

Introduction: Recurrent groin pain following periacetabular osteotomy (PAO) is a challenging problem. The purpose of our study was to evaluate the position and dynamics of the psoas tendon as a potential cause for recurrent groin pain following PAO.

Methods: Patients with recurrent groin pain following PAO were identified from a single surgeon series. 386 PAO procedures were performed between January 2013 and January 2020. A total of 13 patients with 18 hips (4.7%) had recurrent groin pain and underwent CT scans pre- and post-operatively. 3D models from CT data were created with Mimics (Materialise NV) and the used to manually segment all relevant bony structures. Muscle path of the psoas tendon was accurately represented while taking relevant geometrical constraints into account.

Results: Five out of the 18 hips did not show any malformations at the osteotomy site. Thirteen hips (72%) showed malformation secondary to callus classified into: (1) osteophytes at osteotomy site (2) hypertrophic callus or non-union and (3) malunion at the osteotomy. Mean minimal distance of the psoas tendon to osteophytes was 6.24 mm (n=6) and to the osteotomy site was 14.18 mm (n=18).

Conclusions: Recurrent groin pain after PAO needs a thorough assessment. One need to have a high suspicion of psoas issues as a cause. 3D CT scan may be necessary to identify causes related to healing of the pubic osteotomy. Dynamic ultrasound of the psoas psoas tendon may help in evaluating for psoas impingement as a cause of recurrent groin pain in these cases.

Purpose: The role of pelvic incidence (PI) or measurement of other pelvic parameters such as sacral slope (SS) and pelvic tilt (PT) in hip osteoarthritis(OA) leading to Total Hip Arthroplasty (THA) is unclear. Therefore, we undertook this study to evaluate if pelvic incidence has any relevance in degenerative hip disease leading to THA. Method: This cohort study piloted on 120 people, 60 normal individuals as control group and 60 who underwent THA due to degenerative joint disease. We measured PI, SS and PT preoperatively in 60 patients with severe osteoarthritis who underwent THA and compared it with 60 normal individuals. SPSS 20 for windows used to analyze the data. Result: The demographic characteristic of two groups were not significantly different. The mean PI angle were 50.5 degrees (27.9 - 84.5) in control group and 51(27.7 to 78.1) in patients with hip OA (P>0.05). The mean PT were 12.6 degrees (1.0-25.0) in controls and 11.2 degrees (1.8 and 24.8) in patients (P>0.05). The mean SS were 39.1 degrees (19 to 60.), and 44.4 degrees in patients with hip OA (P>0.05). Conclusion: Our study showed that standing spinopelvic parameters in patients with hip OA ins not significantly different from patients without hip disease.

Introduction: The management of anticoagulation in patients undergoing arthroplasty remains a challenge. Guidelines for perioperative management of long-term warfarin recommend discontinuation of warfarin preoperatively in low risk patients. We hypothesised that patients who had their warfarin continued during the perioperative period would have shorter hospital stay and no significant increase risk of surgical complications compared to patients who had their warfarin interrupted.

Methods: a retrospective review of 20 consecutive patients receiving long-term warfarin who underwent total hip replacement without stopping warfarin. As a control group, we collected same data from 20 age and gender matched patients also on long term warfarin but their warfarin was stopped prior to surgery and restarted postoperatively.

Results: There was no significant difference in age, BMI or comorbidities between the 2 groups. There was a statistically significant difference between the two groups in postoperative INR (P < 0.0001) levels. The mean drop in Hb postoperatively was 25.95 g/L in the warfarin group and 35.7 g/L in the control group, which was statistically significant (P=0.0066). Hospital stay was statistically significant with shorted stay observed in the warfarin group (P=0.0447). The odds ratio for developing a postoperative complication was 1.5882 which was not statistically significant (P=0.6346).

Conclusion: Our results support the hypothesis that it is safe to continue warfarin in patients on long term anticoagulation undergoing total hip replacement. Continuation of warfarin was associated with significantly shorter hospital stay and less INR fluctuations. There was no significant increase in the risk of complications or blood transfusion.

Introduction: Incidence of Hip fractures both neck of femur and trochanteric fractures were increasing with improving life expectancy and aging population in the developing countries. Asian projective study estimated India to have 800,000 hip fractures by 2050. Mortality rate ensuing trends like in western countries ranging from 5% - 10% at one month and 15% - 40% at one year will burden any healthcare infrastructure with inadequacy. Materials and Methods: Retrospective analysis performed in cohort of 167 patients above 60 years of age for two years between January 2017 to December 2018 at Meenakshi Mission Hospital and Research Centre, a tertiary hospital at Madurai, South India. Patients with polytrauma, pathological fractures and recent contralateral hip fractures were excluded. Neck of femur fractures were treated by hemi arthroplasty of Total hip arthroplasty and trochanteric fractures by osteosynthesis. Follow up of the patient were performed at 6 weeks, 3 months and at one year. Results: Average age of our patients were 70.8 years and mean duration from injury to surgery is 2.9 days. Surgery was performed within 48 hours following hospitalization in 83% of our patients. The mortality rate was 2.4% (P<0.5) at one month and 14.9% (P<0.5) at one year. Duration between injury and surgery, ASA grade > 2 and post-operative complication were three parameters significantly associated with mortality rate. Conclusion: Mortality rate in our study is lower compared to developed countries at one month and one year. Availability of all specialties with immediate efficient post-operative management of complication

Introduction: Orthopaedic rehabilitation of adolescences and young adults with high dislocation of the femur is rather challenging. The role of palliative salvage procedures is controversial enough in the cohort of patients.
Purpose: Review of long-term outcomes of pelvic support osteotomy (PSO) performed for adolescences and young adults with developmental dislocation of the hip
Materials and methods: Treatment outcomes of 10 patients with congenital hip dislocation were analyzed. Mean age at intervention was 17,8 years (15-22). The grade of dislocation were assessed according to Eftekhar: type C – 2, type D - 8. The mean baseline shortening was 4.7±0.36 cm. All subjects underwent PSO with the Ilizarov method. Another osteotomy for lengthening and realignment was produced at the boundary of the upper and middle third of the femur. The mean time in the Ilizarov frame was 5.3 months
Results: The mean follow-up was 2.6±.1 years (range, 15 to 32 years). Limb shortening of 1 cm to 11/2 cm was observed in four cases. Functional outcomes according to d'Aubigne-Postel were: Pain 4,4±0,15 points. ROM – 4,1±0,3 points. Walking ability – 4,5±0,2 points. Two cases had good results (15-17 points), and seven patients had fair outcomes (12-14 points). A poor result (7 points) was recorded in one female patient 28 years after PSO followed by THA.
Conclusions: Hip reconstruction with the Ilizarov method can be used in specific clinical situations as an alternative salvage procedure to delay THR in young patients with high dislocation of the femur.

Background
Intertrochanteric hip fractures are prevalent in our population, for which the Synthes® PFNA cephalomedullary nail is a commonly used fixation device. A distinctive but understudied mode of failure of this implant is the ‘cut-in’, where there is axial migration of the blade. This study aims to develop a reproducible biomechanical model to induce this clinical phenomenon, as well as to determine clinically relevant factors that prevent this mode of failure.

Methods
Groups of osteoporotic femur models with induced similar intertrochanteric fractures had PFNA nails implanted and were tested according to intramedullary canal diameter (16, 18mm), PFNA nail diameter (9, 12mm) and proximal nail fit (snug, loose). They were subject to cyclic bidirectional loading to simulate physiological gait. A novel load applicator was 3D-printed to engage the femur head. The number of cycles to ‘cut-in’ failure for each group was determined.

Results
12mm diameter nails (2256±375) failed earlier than the 9mm nails (9938±2107) (p=0.016); 18mm canal diameter femurs failed earlier (7532±439) than 16mm femurs (9938±2107) (p=0.003); Snug proximal nail fit models were more resistant to failure (7532±439) compared to loose fit models (1216±634) (p<0.001).

Conclusion
Nail toggling, contributed by a larger canal and looser proximal fit may predispose to ‘cut-ins’. A larger diameter nail also culminated in earlier failure, which may be explained by its increased shaft stiffness inducing decreased bending during axial loading and thus reciprocally channeling the force towards the blade-head interface. We recommend surgeons to use proximally tight fitting and smaller diameter nails during PFNA surgery.

Introduction: The aim was to assess the fixation failure rate of reverse oblique hip fractures and determine the non-union/delayed union rate. Methods: Retrospective analysis was conducted between 01/01/2018 to 31/12/2021. Adult patients with a closed and isolated AO/OTA 31-A3 hip fracture were included. Results: 70 patients were included in this study of which 31% were males (n=22) and 69% were females (n=48). The mean age was 83 years (SD +/- 13.96). All patients had a Simth & Nephew Intertan unreamed long intramedullary nail inserted. Only 22% of patients (n=15) had additional fixation with a cerclage cable. Of the patients who did not have additional fixation (n=55), 16% (n=9) underwent revision surgery (revision nail = 2, cables = 5, hemiarthroplasty = 1, plate fixation = 1). Revision surgery was not required in patients who had cerlage cables. 75% of patients who did not have additional fixation experienced post-operative pain, 22% had non-union (p=0.029) and 51% had delayed union (p=0.0009). The average neck shaft angle in patients who did not have cerclage cables was 122.7 degrees, which was statistically significant for non-union and delayed union (p=0.012). The lateral femoral wall (LFW) displacement was determined as 11.78 +/-6.77mm in the group without cerclage cable and 0.58 +/- 0.82mm ( p=0.001) in the group where cerclage cable was used. Conclusion: This study shows that additional fixation is required to prevent revision surgery. For adequate fracture reduction, the ideal neck shaft angle is between 125 -135 degrees and LFW displacement should be at a minimal.

Introduction
The aim of this meta-analysis was to establish the time for RTS following THA & HRA.

Methods
A search was performed on PUBMED, MEDLINE, EMBASE, the Cochrane Library for trials on HRA and RTS, in the English language, published from the inception of the database to October 2020. The PRISMA guidelines was used to undertake this study.
Results
The initial literature search identified 3,288 studies. 22 studies (11 for THA and 11 HRA) matched the inclusion criteria. Of these 11 studies were HRA with a total of 659 patients matched the inclusion criteria. Two studies involving a total of 94 patients demonstrated an overall pooled proportion of 91.8% (95% CI 71.8-100) of patients' RTS by three months post-operatively. Four studies including a total of 265 patients determined a pooled proportion of 96.8% (95% CI 91.0-99.7) of patients able to RTS by the 6-month post-operative stage. In contrast, the 11 studies for THA had 2297 patients of which three studies with 154 patients demonstrated an overall pooled proportion of 40.0% (95% CI, 32.5–47.9%) of patients RTS between 2 and 3 months after surgery. 4 studies with 242 patients demonstrated an overall pooled proportion of 76.9% (95% CI, 71.5–82.0) of patients RTS by 6 months after surgery. Pooled proportion analysis from seven trials with 560 patients demonstrated 93.9% (95% CI, 82.7–99.5%) of patients RTS between 6 and 12 months after surgery.

Conclusion
Pooled proportion analysis showed increasingly more patients were able to RTS following THA and HRA over the first year.

Purpose: Acromegaly is a rare and chronic hormonal disorder frequently seen in adulthood. In patients with active acromegaly, there are multiple joint related problems, however acromegaly-related arthralgia (AA) is one of the most common musculoskeletal complications. This retrospective study aims to analyze the long-term clinical outcomes and reasons for revision among patients who underwent a total hip arthroplasty (THA) for AA at our institution. Methods: We included all patients who underwent total hip arthroplasty due to secondary osteoarthritis related to acromegaly between January 2001 and December 2019 at our institution. There were 15 patients (22 hips) with a mean follow-up of 12 years (range 4-20). Survivorship free of component revision was determined using Kaplan-Meier analysis. Patient-reported clinical outcomes were assessed using Harris Hip Scores. Results: At the final follow-up, the status of the implant was known in all 15 hips. No patients were lost to follow-up. Five patients (9 hips) were deceased. Three hips (14%) underwent a revision surgery at a mean of 6 years (range 3-10). Survivorship free of component revision was 81% at 15 years. Mean Harris Hip Scores at final follow-up were fair (mean 64.3, range 32 - 91), but significantly improved compared to preoperative scores (p<0.05). Conclusion: Acromegaly is a rare disorder that has direct effects on bone and joints. Our results suggest that THA can result in successful clinical and functional outcomes in patients with AA of the hip however the risk of aseptic loosening should also be considered in this patient population.

INTRODUCTION:
Aseptic loosening of the acetabular component presenting with Intrapelvic migration remains a challenging condition to deal with. Especially because of its proximity to vascular structures and associated peri-Implant fibrosis decision making to retain or remove the component is crucial. We used an algorithm based protocol for management of such cases. The aim of this study was to (a) Formulate an algorithm to decide whether to remove or retain the migrated component (b) Assess the functional and clinico-radiological outcome, and (c) Survivorship.
METHODS:
From August 2014 to June 2019, a total of 14 patients of aseptic loosening of acetabular component with intrapelvic migration were operated, which included 12 revisions and 2 re-revision total hip arthroplasties. Acetabular reconstruction was completed by using either the Trabecular Metal Shell or one of the modern porous metal cup supplemented with multiple screws.
RESULTS:
All patients were available for latest follow up with a minimum follow up of 24 months and maximum of 59 months. Component was retained in 5 cases. Graft incorporation was seen in all 14 cases. In all 14 cases, there was no evidence of component migration or loosening. The mean Harris Hip Score improved from 53.5 preoperative to 87.5 at the latest follow up.
DISCUSSION AND CONCLUSION: The algorithm based approach allows retention of migrated components in selected cases, which is an improvement over the conventional removal of all loose implants. Short term results of this study showed good clinical and functional outcome.

Introduction: Per trochanteric fractures in elderly are highly unstable and osteoporotic. Comminution and distraction of fragments makes internal fixation and subsequently union, surgically challenging and might warrant prolonged bed rest with protected weight bearing to prevent the implant failure owing to forces acting at the hip joint. Bipolar Hemi-arthroplasty is an effective and viable alternative. Material and Methods: 30 patients with Per-trochanteric femur fractures were randomized and operated with bipolar hemiarthroplasty, between December 2019 and November 2021. The inclusion criteria were patients more than 65 years of age, Type 4 intertrochanteric fracture (As per Evans classification) AO/ OTA type 31A2.3, 31A3.2, 31A3.3. Patients with polytrauma, compound injuries, pathological fractures and medically unfit Patients were excluded from the study. Harris hip score was used to evaluate the functional outcome. Results: Mean age was 67.8 years. The most common mechanism of injury was domestic fall comprising of 80%. Females were more affected. The average duration of surgery from the time of injury was 3.5±1.5 days. The average surgical duration was 85.5mins. The average duration of stay in hospital was 8.5±1.5 days. Final results were calculated using the Harris Hip score with 40% cases as excellent, 50% cases as good, 10% cases had fair results respectively at 2 years of follow up. Follow-up was done at 1.5, 3, 6, 12 and 24 months. Conclusion: Bipolar hemiarthroplasty in Per-trochanteric femur fractures has an advantage of stable adequate fixation with early return to activities of daily living, thus preventing serious life-threatening complications.