Introduction: Due to high rate of complications like nonunion, avascular necrosis and revision surgeries, treatment of neglected fracture neck of femur in young adults by osteosynthesis, is always a great challenge to treat. In spite of this high rate of nonunion, osteosynthesis is preferred over replacement as the treatment option for these fractures in young adults. Augmented osteosynthesis by fibula although has increased the union rate, but still the nonunion rates are unacceptably high. Material & methods: We treated 40 patients of neglected fracture neck of femur with cannulated cancelleous screws in apex down configuration. Osteosynthesis was augmented with autologous fibular graft which was harvest and modified in a special manner to aid in union. Results: The mean age of the patient was 33.5 years (range 17 – 50 years) and mean delay at presentation was 26 days (range 15 to 61 days). The mean duration of follow up was 24 months (range from 12 – 36 months). Union was achieved in all patients except two who needed revision surgery. One had graft breakage due to early weight bearing. Conclusion: Modified augmented fibular grafting for neglected neck of femur fracture in young adults assures excellent long term outcome with rate of fixation failure and nonunion < 5%.

The COVID pandemic has left millions waiting for joint replacement surgery across the world. Innovation and efficient perioperative pathways are required to combat ever growing waiting lists.

Day Case Arthroplasty provides a solution by eliminating the need for inpatient capacity thus allowing increased efficiency. Formulating a successful effective pathway is best completed by recognizing patients that would prefer day case arthroplasty and by identifying perceived barriers, allowing effective perioperative protocols to be designed. Understanding our patients will optimize the likelihood of successful implementation of such a service.

Data was collected at routine preoperative assessment for arthroplasty patients using an anonymized structured questionnaire using both quantitative and qualitative methods. The questionnaire covered patient demographics and common concerns relating to same-day discharge. Patient preference for day case arthroplasty was also established.

79 patients were included with 43% of patients preferring same-day discharge. Patients who preferred same-day discharge were statistically younger. Postoperative pain, surgical complications and wound healing were the most significant concerns elicited. Common themes emerging from free text identified previous bad experiences with postoperative complication with patients favouring inpatient stays as a result.

The results not only highlight the demand in our cohort for day case arthroplasty, but also, identifies important information to formulate effective perioperative protocols to ensure successful implementation. Similarly, our data can inform setup of successful day case services across the world to increase capacity for joint replacement surgery.

Introduction: The aim was to identify the failure rate of internal fixation and hemiarthroplasty in patients aged 60 years or over with Garden 1 or 2 hip fractures. Methods: A multicentre retrospective analysis was conducted between 01/01/2015 - 31/12/2020. Patients managed conservatively, treated with a total hip replacement or missing data were excluded from the study. Results: 1273 patients were included. 71.8% were female and the mean age was 83 years. 26.2% (n=3334) of patients had cannulated hip screw fixation (CSFN), 19.4% (n=247) had a dynamic hip screw (DHS) and 54.7% (n=692) had a hemiarthroplasty. 66 patients (5.2%) required revision surgery; there was as statistical difference between the revision rates among CSFN, DHS and hemiarthroplasty patients [14.4% (n=48) vs. 4% (n=10), vs 1.2% (n=8); χ² test p=0.000015]. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CSFN group [88.5% (n=23) vs. 11.5% (n=3) in DHS; χ² test p=0001]. The predictive risk factors for CSFN revision were age >80 (t-test, p=0.021), female gender (χ² test, p=0.047), smoking (χ² test, p=0.035). For DHS, smoking was a predictive risk factor (χ² test, p=0.0002). The average length of hospital stay was decreased when using CSFN compared to DHS and hemiarthroplasty and the mortality rate for CSFN, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively (log rank test, p=0.113). Conclusions: Female patients over the age of 80 have a higher rate of fixation failure with CHS. A viable choice in such patients would be hemiarthroplasty.

Introduction:we aimed to evaluate the accuracy of the preoperative cup and stem size digital 2D templating of THA with mediCAD® software and find the factors that influence the accuracy such as indication for surgery, patients’ demographics, implant brand, and the assessors’ grade of education.Methods:We retrospectively retrieved 420 patient template images of all patients who underwent THA. Templating of all included images was processed using mediCAD® software a day before surgery by a newcomer physician to hip arthroplasty course . Preoperative templating cup and stem sizes were compared with the actual inserted implant sizes. Result: The average cup sizes predicted before and after surgery were 52.12±1 4.28 and 52.21±15.05 respectively, and The mean delta cup size(before and after surgery) was 2.79±2.94. The delta stem size before and after surgery has a mean value of 1.53±1.49. The acetabular cup components, measured within ±0, ±1, and ±2 sizes, were 28.9%, 63.9%, 83.1% accurate, respectively. The femoral stem design component measured within ± 0, ±1, and ±2 sizes were 27.2%, 61.0%, 78.6% accurate, respectively. Wagner Cone® stem brand, DDH patients, and females showed significantly higher accuracy of stem size templating. Revision THA has the lowest accuracy in terms of cup size templating.Conclusion:Our study showed that under mentioned condition, templating using mediCAD® has acceptable accuracy in predicting the sizes of femoral and acetabular components in THA patients. Digital software like mediCAD® remains favorable because of the short learning curve, user-friendly features, and low-cost maintenance, leading to level-up patient care and THA efficacy.

Introduction: Osteosynthesis by cannulated cancellous screw in inverted triangular configuration (CCSI) is accepted treatment for fracture neck of femur (NOF) in young adults with advantages of lesser operative time, blood loss and hospital stay, but at the cost of moderate fixation strength. Novel Biplane Double Supported Screw Fixation (BDSF) configuration provides increased stability by establishing two supporting points laid in two planes. Material and methods: We compared the outcome of BDSF versus CCSI in management of fracture NOF in 60 young adults (30 each). Results: Mean age was 39.5 years (range 22 to 55 years). Mean blood loss, duration of surgery, VAS and Harris hip score in BDSF and CCSI was 63.13 ml, 2.10 hr, 2.29, 86.2 and 53.53 ml, 1.58 hrs, 4.59 and 77.6, respectively. 20 patients in BDSF group has good to excellent results in comparison to 6 patients in CCSI group. All patients united, except 2(2 in CCSI, 1 in BDSF). Screw back-out was 3 cases of BDSF and 5 cases of CCSI. Conclusion: Both BDSF and CCSI being closed method, preserve fracture hematoma, avoid excessive soft tissue dissection, and have shorter operating time and less periosteal stripping. But owing to better fixation strength BDSF is superior to CCSI in terms of early mobilization, enhanced and early union and better functional.

Background: The hip fracture is the leading cause of disability and deaths in elderly. The aim of this study was to determine the predictive values of the functional status, present comorbidities, and the types of treatment on the long-term functional status and mortality in patients with the hip fracture. Subjects and methods: We analyzed the data about the patients with the hip fractures treated in General Hospital Sarajevo in the period between 01.07.2006. and 01.07.2016., with the mean follow-up period between 34.3±4.9 months. The data included radiographs, age, comorbidities, functional status on admission, functional status on discharge, and follow-ups. Results: sex, age, and poorer functional status upon admission, conservative treatment, trochanteric fracture, the presence of neurological or lung disease, diabetes, were all significant risk factors leading to poorer functional outcomes on the latest follow-up (p < 0.05). On the other hand, the patients who were mobile upon admission had a longer survival (38.1±3.51 months) as compared with the other patients (12.3±5.1 months; χ2=25.202, p = 0.001). Besides, the results of this study revealed that the direct, statistically significant relationship exists between the untreated internal and neurological diseases, and increased mortality and poorer functional outcomes on the latest follow-up. Conclusion: These results are useful for the orthopedic and trauma surgeons, who are treating these patients, the physical medicine and rehabilitation specialists, who are performing the rehabilitation of these patients, but also the health policy makers, who may promote the programmes of healthy aging (treating the diseases, maintaining fitness, etc.)

Introduction: Posteriomedial integrity is emphasized in comparison to lateral trochanteric wall as prognostic factor in intertrochanteric (IT) fractures. Disrupted lateral wall converts an IT fracture into reverse oblique fracture, leading excessive collapse and varus. Unlike trochanteric Stabilizing plate, no lateral buttress plate is available with proximal femoral nailing (PFN), which are implant of choice in unstable trochanteric fractures. Material and methods: 60 patients of IT fracture with broken lateral wall were treated with PFN alone or with additional lateral wall buttress plate along with PFN and were compared for union, functional outcome and intraoperative parameters blood transfusions/blood loss, duration of surgery and exposure. Results: Mean age was 60.5 years (range 42 to 68 years) and mean follow up was 10.2 months (7 to 26 months). All cases united, without any secondary procedure. Mean blood loss, duration of surgery and exposure in PFN along and PFN with lateral wall buttress was 93 ml and 144 ml, 64 min and 91 min, and 32 and 56 shoots respectively. Mean harris hip score and union time in PFN along and PFN with lateral wall buttress was 87 and 94, and 5.3 and 4.9 months respectively. Conclusion: Augmentation of PFN with buttress plate, improves functional and radiological outcomes compared to PFN along in broken lateral intertrochanteric fractures.

Introduction: End-stage degenerative joint disease (DJD) in hip joint not only affect patient’s quality of life and activity of daily living but also affect other adjacent joints. In this order, long lasting hip DJD could force pelvis to tilt in coronal plane (pelvic obliquity) also could affect sagittal lumbo-pelvic balance. In this study, we assessed how pelvic obliquity will change in early stage following total hip arthroplasty.
Method: All total hip arthroplasty patients were extracted from institutional database from January 2015 to January 2018. All preoperative pelvic anteroposterior radiographs were observed by one of researchers and all patients with pelvic obliquity were included. Postoperative radiographs were assessed by the same researcher and pelvic tilt in coronal plane were calculated. With mediCAD 3.5 all data
Result: present study included 730 patients who underwent THA. The results of PO angle changes in early post-operative showed that, 56.7% of patients had no change, 18.5 % get worse with mean of 3.39 degrees, 13.2 % had reversed with a mean of 7.23 degrees, 8.2 % had improvement with mean of 5.38 degrees and 3.2 % had improvement in PO angle but had not normal alignment.
Conclusion: According to our findings, pelvic obliquity changes could categorized in five groups, patients with worsening of pelvic obliquity in same direction, no change in pelvic obliquity, improve obliquity but not normal, patient who had no pelvic obliquity after the surgery (entirely became normal with THA) and patients who had reverse pelvic obliquity in opposite direction following the surgery.

Introduction: There is no distinct classification system to evaluate the bone defect in previously managed acetabular fractures. We propose a new classification system for bone defect evaluation in such conditions that will be helpful for total hip arthroplasty (THA).
Materials and methods: The preoperative pelvis radiographs of 99 THA patients with previous acetabular fractures and minimum two years of follow-up were evaluated by 10 experienced surgeons (Paprosky and new classification systems). The five types of bone defects in the new classifications were circumferential, posterior wall, posterior column, both column defect, and anterior column. The interobserver and intraobserver reliability was calculated, and the consensus management plan was based on the recommendation of the observers.
Results: There was fair interobserver reliability for Paprosky classification (alpha coefficient 0.39) and substantial interobserver reliability for the new classification (alpha co-efficient 0.71). There was substantial intraobserver agreement for the new classification (kappa 0.80) and moderate intraobserver agreement for Paprosky classification (kappa 0.55). Sixty-nine patients who were treated as per the management plan of the observers reported significant improvement in modified Harris hip score (improved from 25 to 85.88, p<0.001). 89.7% of patients reported good to excellent outcomes. EQ-5D VAS showed the best health in THA following anterior column fracture (EQ-5D VAS 97.5), and poor health after posterior column nonunion (EQ-5D VAS 80).
Conclusions: The new classification system for bone defect evaluation in previously treated acetabular fractures is valid and reliable. The proposed surgical plan for management of bone defects in THA provided good to excellent outcomes.

Introduction:. In the current study, the outcomes of total hip arthroplasty (THA) after failed fixation of intertrochanteric fractures using dynamic hip screw (DHS) were investigated. Methods: There were 203 patients included in the current study. All of them underwent total hip arthroplasty through direct lateral approach. The indications of the failure were nail cut out in 174 (85.7%), non-union in 15 (7.3%) and plate failure in 14 cases (6.8%). One patient underwent two-stage protocol due to infection. We evaluated the possible clinical and radiological complications and measured functional outcomes using modified Harris hip score (MHHS). Cementless cup was used in 95.2% of the patients and cementless long stem in 88.1%. Results: The patients were followed for 4.43±1.11 years. The mean (MHHS) was improved from 45.32±12.41 (range 40-49) to 89.37±7.41 (range 85-98) significantly (P=0.002). There was no infection, no reoperation, no dislocation, no nerve palsy, no avascular necrosis, no pulmonary embolism (PTE) and deep vein thrombosis (DVT). There was only one intra-operative fracture which was treated successfully. All of the patients were ambulatory at the last visit. Conclusions: THA in patients with failed DHS resulted in good functional improvement without any major complications. Though technically demanding, properly performed hip arthroplasty can be a good replacement option for this patient population.

BACKGROUND: Reverse oblique intertrochanteric fracture AO 31A3 are rare, unstable and challenging injuries. Being unstable due to posteromedial comminution with lesser trochanteric fragment and lateral wall defect intramedullary nail has better potential to give stable fixation. We studied and analyzed different subtypes of AO31A3 (1,3) and compared clinical and radiological results in different subtypes using intramedullary nail (PFN) with or without augmentation. MATERIALS AND METHODS: This was a prospective study of 25 patients from 2017- 2020 carried in tertiary Government Hospital in Central India. There were 18 patients of AO/ OTA 31A3.3, 5 of AO/ OTA 31A3.1 and 2 of AO/ OTA 31A3.2. All patients were operated with proximal femoral nail with augmentation if required. Patients were followed for minimum 6 months or up to union. Clinical and radiological union, functional outcome and complications were noted. RESULT: 6/18 AO/ OTA 31A3.3 required augmentation by cerclage wire for reduction or for better stability. Mini open or open reduction was required in 8/25. Augmentation required on an average 15-30 minutes more time. We had 2 patients of non-union, 1 in augmented and 1 in non- augmented group. Union time was 16.4 weeks in augmented group 17 weeks in non- augmented group. CONCLUSION: Anatomic reduction is of utmost importance in reverse oblique fractures. Augmentation is required in 33% of AO/ OTA 31A3.3 of reverse oblique intertrochanteric fracture treated with PFN. It increases stability of fixation and is safe, effective if done respecting biology. KEY WORDS- reverse oblique intertrochanteric fracture, augmentation, unstable fractures.

Introduction: The radius of curvature (RoC) of femoral intramedullary nailing (IMN) is a design feature which accommodates the anatomical femoral bow and its magnitude can vary between IMN designs. The local IMN used in our institution is the Gamma III, which has a larger RoC than its competitors. We aim to assess the impact of its design on intraoperative decision making and implant related complications. Methods: Patients with femoral neck fractures that underwent Gamma III nail procedures from January to April 2020 were reviewed. Radiographs and operative notes were reviewed to calculate the distance of the nail tip to the anterior cortex of the femur. The distance of the nail tip to the anterior femoral cortex was divided into 5 zones (Zone A to E), with A being most anterior and E being most posterior. Results:
102 patients were included ranging from ages 19 to 97 years. There were 6 out of 102 patients’ operation notes that had comments of deliberately shortening the nail, 4 about notching of the anterior femoral cortex and 1 requiring the use of a supplementary plate. There were 28 nails categorised into zone A, 46 in zone B, 26 in zone C, 2 in zone D & none in zone E. Conclusion: Approximately 6% of patients required undersizing of IMN length in order to avoid notching of the anterior femoral cortex. Almost a third of the cases were categorised into zone A, suggesting that they are predisposed to a higher risk of periprosthetic fractures.

Introduction: Posterior wall fractures are the most common acetabular fractures. Majority are comminuted with associated marginal impaction. In this study, we have prospectively evaluated the functional and radiological outcomes as well as surgeon independent and approach specific prognostic parameters and various risk factors of unsatisfactory results. Methods: A total of 103 cases in the age group of 18-65 years with displaced isolated posterior wall fractures were enrolled in the study during the period of June 2009 to January, 2019. All these patients were operated by single operating surgeon with expertise in fixing pelvi-acetabular fractures. They were evaluated for functional, radiological outcomes and various risk factors for a minimum duration of 2 years.Results: All patients were grouped under AO/ASIF classification with A1(46), A2(36) and A3(21). Anatomic reduction(Matta’s criteria) was achieved in 62 patients, imperfect and poor in 27 and 14 patients, respectively. The clinical outcome at the time of final follow-up was graded as excellent(78), good(8), Fair (7) and poor (9) [Merle d’Aubigne score]. 66 patients had an associated posterior dislocation of the hip, heterotrophic ossification developed in 23 patients, osteonecrosis of femoral head in 6 patients, sciatic nerve palsy was evident in 11 cases.Conclusion: Posterior wall acetabular fractures are complex orthopaedic injuries that need expert care for optimal functional recovery. Surgically treated fractures of the posterior wall of the acetabulum has shown satisfactory results in most patients. Availability of infrastructure and expertise of the treating surgeon could be the major factor that lead to satisfactory outcome.

Background: Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the oldest old have worse outcomes with surgery. However, these studies inherently inflate risks given poor handling of confounders and inadequate age-stratification of their geriatric population.

Aim: This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery.

Methods: This is a retrospective single institution cohort study. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups [Ultra-old (≥85 years) vs old (<85 years)] and underwent 1:1 matching. Baseline demographics and the ASA (American Society of Anesthesiologists) status, and the Modified Barthel’s Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow up period of ≥2 years.

Results: 754 patients were in each matched age group. 1-year mortality was similar for both age groups (4.1% ultra-old vs 4.6% old, p=0.438). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (11.9% vs 6.4%, p<0.001). MBI scores at 1-year were lower in the ultra-old.

Conclusion: Surgical treatment for hip fractures in patients aged ≥85 years does not result in worse 1-year mortality. Patients aged ≥85 years are at higher risk for pneumonia postoperatively, and for poorer function at 12 months.

Introduction: Periprosthetic femoral fracture (PFF) is a serious complication following hip arthroplasty (HA) and its volume is expected to rise due to an increasing age of the population. While current guidelines propose revision with long-stemmed prosthesis for all Vancouver B2 PFF, recent papers of small case series suggest equivalent outcome with open reduction and internal fixation (ORIF). The purpose of this study was to evaluate under which circumstances ORIF leads to a favorable outcome in Vancouver B2 PPF.

Methods: A billing query identified 78 patients who had undergone ORIF for Vancouver B2 PPF utilizing a 4.5 mm LC-Plate over a 5-year period. Medical records were reviewed for demographic data, stem fixation (metaphysis/diaphysis), complications and mortality. Radiographic charts were reviewed for anatomic fracture reduction, secondary stem subsidence and fracture healing. Fisher`s exact test was used to compare the variables anatomic fracture reduction and stem fixation method on secondary stem subsidence. A p-value of 0.05 for significance was set.

Results: At a minimum of two year of follow up, 21 (26.9%) patients showed a secondary stem subsidence, however none of the patients sustained a hip dislocation. Fractures that were anatomically reduced during ORIF showed a significantly lower rate of secondary stem subsidence (p<0.001). Femoral stems with a metaphysis fixation showed a significantly lower rate of secondary stem subsidence (p<0.007) compared to diaphysis fixated stems.

Conclusion: Anatomically reduced fractures and primary metaphysis femoral stem fixation are associated with a lower rate of secondary femoral stem subsidence following ORIF in Vancouver B2 PPF.

Introduction: We previously presented the outcomes of 83 revision THAs using Jumbo cups in patients with large acetabular defects. In the current study, the data of new patients were added to the previously studied patients and long-term outcomes of the previous participants were investigated. Methods: Between 2004 and 2021, there were 127 patients with large acetabular defects underwent uncemented revision total hip arthroplasty (THA) using Jumbo cups. The patients were followed for 10.2±4.7 years. Results: Aseptic implant loosening occurred in 9 patients who underwent re-revision THA. Postoperative dislocation was occurred in 5 patients. Radiolucency around the bone-implant interface was found in 11 patients without prosthetic instability and loosening. Three patient developed infection. There was 2 thromboembolic events in the current study in one of the resulted in the death of the patient. The Harris hip score (HHS) averaged 75.5±13.4. Based on the HHS, the functional outcomes were excellent in 29 patients, good in 45 patients, fair in 37 patients and poor in 16 patients. Conclusion: The findings of the current study confirms the results of our previously presented study. Implantation of Jumbo cups in revision THA for patients with large acetabular defects was safe and resulted in satisfying outcomes.