Introduction: Developmental Dysplasia of Hip(DDH) is a major cause of hip DJD in young population. Total Hip Arthroplasty considered as a gold standard treatment of DDH. Due to soft tissue contracture, there are a risk of neurological injury in the cases with LLD more than 4 CM, previous surgical scars and high-ride DDH following THA. Many studies supported femoral shortening osteotomy could reduce the risk of neurological deficits. There are imitated studies, which who would have done THA without shortening osteotomy. Purpose: to evaluate the clinical and radiological outcome of THA on high-ride DDH patients without shortening osteotomy with Direct Anterior (DA) approach. Method: Between January 2017 to January 2021, 57 patients(78 hips) with overriding DDH(Crow Type-4) retrospectively were included in this study. A THA was performed for all the patients without any shortening osteotomy with DA approach. The patients were aged and followed with a means of 44.3 ±13.3 and 32.1 months(12 to 46 months), respectively. Result: All the patients underwent THA without shortening osteotomy. In the last follow-up visit, 10(13.5%) hips had dislocation following THA that 9(11.5%) patients were managed with close reduction without reoccur of dislocation and 1(2%) patient needed to a Revision surgery. 4(5.1%) patients had neurological complication(Sciatic Nerve palsy) which recovered after 6 months. The LLD was improved with a mean of 36.2 mm (preoperative: 44.7 mm, postoperative: 10.5 mm). Conclusion: in conclusion, THA without shortening osteotomy in high-ride DDH(Crowe type-4) had excellent outcomes in function, postoperative recovery and LLD improvement with reversible side effects.

Introduction: Acetabular revision in prosthetic joint infection (PJI) is a challenging procedure. In some cases, the need of restoring a correct hip byodinamic could advocate the usage a custom-made acetabular cup or augment.
Methods: 21 patients with important bone loss (Paprosky IIc-IIIa-IIIb) due to PJI were treated with a custom made implant at our Institution. Demographic and relevant clinical data were recorded. Clinical evaluation was performed pre and post-operatively using Harris Hip score (HHS), Oxford Hip score (OHS), Visual Analog scale (VAS) and Leg Length discrepancy (LDD). Implant survivorship was assessed with Kaplan Meyer estimator. Radiographic parameters evaluated were implant mobilization and migration, osteolysis, and calcifications.
Results: The mean follow up was 36,3 months (range 11-69). HHS improved from a preoperative mean value of 27.5 ± 8.1 to 81.1 ± 10.8 postoperatively, OHS from 17.2 ± 11.3 to 39.6 ± 3.6, VAS from 8.3 ± 1.1 to 0.9 ± 1.0 and LLD from 15.9 ± 8.1 mm to 4.6
± 3.9 mm. There was one revision due to infection recurrence (survival rate 95,5%). No migration or mobilization was noticed. In two cases, non progressive osteolysis were recorded. In two patients, calcifications (Brooker 2) were observed.
Discussion: Our cohort was constituted of patients with severe acetabular bone loss: using custom made implant allowed the surgeon to dominate the pelvic defect and to reestablish hip center of rotation.
Conclusion: In a medium term follow up, custom made outcomes seems to be encouraging, but further studies with long term follow up are mandatory.

Background: The femoral stem alignment can influence the outcome of total hip arthroplasty (THA) and thereby increase the chance of femoral component failure. Recently, the critical trochanteric angle(CTA) has been considered as a predictor for stem malposition following THA. We aimed to assess the role of CTA as a predictor of Fitmore® (Zimmer, USA) stem malposition. Method: A total of 167 cementless THA were implanted in patients with unilateral Hip osteoarthritis via the direct anterior approach by one surgeon setting using the Fitmore® stem(Zimmer, USA). Stem alignment was analyzed in postoperative AP pelvic radiographs and correlated to the CTA: the angle crest was defined by the intersection of the femoral shaft and neck axis and the angle was measured between the shaft axis and a leg intersecting the vertex between the lateral and superoposterior facet of the trochanter. Result: The mean total CTA was 23.4°±4.7°. The mean subtotal CTA was 19.6°±3.5°, 25.01°±3.8°, and 26.7°±5.8° in patients with varus, neutral, and valgus stem position, respectively. Binary group analysis showed that CTA was significantly lower in patients with varus stem malposition (p= 0.001) than the two other groups. , the ROC curve analysis demonstrated that a CTA cut-off lower than 21.8° can significantly predict stem varus malposition(P=0.001). Conclusion: we recommended that in the patients with CTA lower than 21.8 degrees, it is necessary to consider postoperative stem malalignment. It is suggestable using intraoperative x-ray with C-ARM in the patients with CTA lower than 21.8 degrees to prevent the postoperative stem varus malposition.

Introduction: Initial implant instability causing increased stem micromotion can lead to implant failure. Recent biomechanical findings suggest that the use of collared stems can ultimately decrease the risk for loosening and periprosthetic fractures.
Materials and Methods: 457 patients who underwent total hip replacement with a cementless collared or collarless double-tapered stem of the same manufacturer (Corail®, DePuy, Warsaw, IN) were retrospectively reviewed. No differences were detected regarding body mass index or comorbidities according to the ASA-classification.
Results: At a median follow-up of 40 months, twelve patients (10.6%) who received a collarless implant had to undergo revision surgery for any reason and in six of these patients (5.3%) the stem had to be revised. In the cohort with a collared stem, 9 patients (2.6%) underwent revision surgery due to any reason and in one case (0.03%) the stem had to be exchanged. Patients receiving a collared stem displayed a significant better overall revision-free survival (98.3% at 12 months, 98% at 24 months, 97% at 5 years) compared to patients receiving a collarless stem (93.8% at 12 months, 93.8% at 24 months and 89.9% at 5 years). (p=.019). Patients with a collared stem also showed a significant better implant-survival (99.7% at 12 months, 99.7% at 24 months and 99.7% at 5 years) compared to collarless stems (98.2% at 12 months, 98.2% at 24 months, 95.1% at 5 years) (p=.033).
Conclusion: The use of a collar leads to superior revision-free survival in cementless stems compared to collarless options.

Study design – prospective observational study
Objectives To study the incidence of bone cement implantation syndrome (BCIS) in elderly patients undergoing cemented stem hip arthroplasty with the use of pulse lavage
Methods- 40 consecutive patients undergoing cemented stem hip arthroplasty enrolled in the study and intra-operative vitals post induction and post cementing recorded at 5,10 and 15 minutes.
Results and Discussion: Study depicted an incidence of 32.5%. The incidence of grade1,2,3 was 22.5%,7.5% and 2.5% respectively. There was a significant correlation between increased age and those patients suffering from BCIS grade 2 and 3. There was no correlation drawn between comorbidities of the patients and presence of the condition, However all the patients with history of dementia, myocardial infarction and stroke developed the syndrome. The severity of BCIS was associated with a significant increase in pre-operative neutrophils and hyponatremia compared to patients with mild condition. Significant decrease in SBP was found in patients with presence of the condition at 5,10 and 15 minutes after cementing, with highly significant decrease in SBP at 5 minutes after cementing. Furthermore significant decrease in oxygen saturation was found 5,10,15 minutes after cementing with highly significant decrease in saturation at 5 minutes after cementing. A severe case leading to cardio-pulmonary collapse post cementing was recorded with positive history of previous stroke, myocardial infarction, hypertension, atherosclerosis and atrial fibrillation.
Conclusion: Thus bone cement implantation syndrome is a commonly occurring phenomena in elderly which is fairly under-reported leading to significant intra-operative complications.

Introduction: Peri-prosthetic joint infection (PJI) is the most fearsome complication after hip and knee arthroplasties. Recently, Leukocyte esterase and alpha-defensin are identified as markers of active infection in synovial fluid. If found reliable, these tests will increase the confidence of surgeon in situations, where the diagnosis of PJI is not established. Methods: This study was conducted on 132 patients in Lahore General Hospital; from August 2020 till December 2021. Leukocyte Esterase strip and Alpha-Defensin kit were used to detect infection in synovial samples taken intra-operatively. Group-A had 31 patients with peri-prosthetic joint infection diagnosed as per Musculoskeletal Infection Society criteria. In Group-B 101 patients were present in whom PJI was not present. Synovial tissue and fluid samples were also send to laboratory for culture and histopathology; so that sensitivity and specificity of Both Kits could be find out. Results: Male to female ratio was 85:47. 31 patients were diagnosed as PJI after primary hip or knee arthroplasty on the basis of serological investigations and culture of joint aspiration. Sensitivity and specificity of LE strips was 90.32% and 95.04%, whereas that of Alpha defensin was 93.54% and 100% respectively. The correlation coefficient between LE strip test and synovial fluid polymorphonuclear neutrophils counts were 0.811 and it was even higher when Alpha-Defensin kit was used (0.845). Conclusion: Both LE and Alpha-Defensin kits are highly specific and sensitive in diagnosing PJI. Alpha-defensin is more accurate but cost effectiveness of LE strip makes it more feasible option.

Purpose: Synovial biomarkers, such as Calprotectin, have become valuable in the diagnosis of PJI. This meta-analysis aimed to investigate the role of synovial Calprotectin as a diagnostic test in PJI. Methods: PubMed, Cochrane, Web of Science, and Google Scholar were searched until February 2022. Inclusion criteria were as follows: all studies in which the patients with joint replacements were evaluated for PJI; synovial Calprotectin was the biomarker of choice to diagnose PJI; standardized guidelines were used as the gold standard for the diagnosis, and a comparison between the guidelines and Calprotectin results was made. Diagnostic parameters such as sensitivity, specificity, diagnostic odds ratio (DOR), positive predictive value, negative predictive value, and area under the curve (AUC) were calculated for the included studies to evaluate synovial Calprotectin for PJI diagnosis. Results: The total number of the included patients was 614 from 8 studies. The pooled sensitivity, specificity and diagnostic odds ratio of calprotectin test were 92% (95%CI: 84%-98%), 93% (95%CI: 84%-99%) and 187.61 (95%CI: 20.21-1741.18), respectively. The results showed that the negative and positive likelihood ratios of the calprotectin test were 0.07 (95%CI: 0.02-0.22) and 9.91 (95%CI: 4.11-23.93), respectively. The SROC showed that the area under the curve for calprotectin test was 0.935. Conclusion: Synovial Calprotectin is a valuable biomarker for the diagnosis of PJI. It has the potential to be used in clinical practice due to its high sensitivity and specificity that are comparable to the other utilized biomarkers. Another advantage is its low cost relative to other biomarkers.

Background: Perioperative blood management in total hip arthroplasty(THA) has become a prime focus of research. Considering the morbidity, delayed recovery, and prolonged hospital stay associated with postoperative anemia, various measures have been proposed to reduce perioperative blood loss(PBL). we have studied the efficacy of bone-wax application on the distal cut surface of femoral neck in reducing PBL during THA through direct anterior approach(THA/DAA) for the first time. Methods: In a randomized controlled clinical trial, 152 patients undergoing THA/DAA were compared in two groups of wax(n=75) and control(n=77). The study was triple-blinded. The primary outcome measures were apparent PBL, measured as the blood content of wet long-gauzes and suction bottle, and total PBL, calculated by well-known formulae based on patient’s height, weight, pre- and postoperative serum hemoglobin on postoperative days(PODs) 3 and 5. Transfusions and complications were also recorded. Results: No significant difference was found between two groups in terms of age, sex, weight, height, BMI, American Society of Anesthesiologists-score, etiology, side, preoperative hematologic/coagulation profile, spinal anesthesia, intraoperative mean arterial pressure, and operation time. Apparent PBL, total PBL on POD3, and POD5 were significantly lower in wax group, as their corresponding medians were 200 vs.370, 505.2 vs.747, and 536.7 vs.767.8mL in wax vs. control groups, respectively(p<0.001). No significant difference in rates of transfusion and complications was found. Conclusions: Bone-wax application on the cut surface of femoral neck can significantly reduce PBL during THA/DAA. It is feasible, accessible, and inexpensive, and could be considered as a routine part of surgical-technique in THA/DAA.

Introduction: Total Joint Arthroplasty (TJA) is an advance surgery for patients with hemophilia who suffer from Joint DJD in early ages. Many studies suggested that General Anesthesia (GA) is might be better for hemophilic patients. There was an attitude spinal or epidural anesthesia could increase chance of bleeding in the patients. We developed present study to explore if using spinal or epidural anesthesia could affects complications, bleeding and outcome of hemophilic patients.Method: from January 2010 to January 2019, we retrospectively included 116 hemophilic patients (114 male, 2 female) who underwent a TJA. The patients were followed with a mean time of 60 months (range: 3 to 110 months) and aged with a mean of 36.4 ±8.5. Anesthesia types were extracted from HIS (Hospital Information System) for all patients. The TJA distribution were 96 TKA, 13 THA, 6 Revision TKA and one Revision THA.Result: From 116 patients were included to current study, the anesthesia type distribution were 54 GA, 46 spinal Anesthesia, 7 Epidural Anesthesia and 1 combined Epidural and spinal anesthesia in hemophilic patients. For 8 patients were planned Epidural and Spinal anesthesia but because of operation time lengthening, GA was performed for the patients. All patients were followed in early and long post-operation. There were no complication including Bleeding, Anemia and VTE in the patients in final follow-up.Conclusion: we explore that there were no differences depending on anesthesia types in hemophilic patients who underwent TJA. Therefore, it is suggestable using spinal anesthesia in TJA for hemophilic patients.