Background. Post-operative acute kidney injury is significant complication following surgery. Patients who develop AKI have an increased risk for progression into chronic kidney disease, end-stage renal failure and increased mortality risk. The patient outcomes following total knee replacement (TKR), who develop AKI has been a topic of interest in recent years as it may have patient and medicolegal implications. Nevertheless, there are no studies looking at the incidence, risk factors and outcomes of AKI following bilateral TKRs at the same sitting. Objectives. To determine the incidence, risk factors and outcomes of post-operative AKI following bilateral TKRs surgery at the same sitting. Methods. This was a retrospective single-centre study performed at the Princess Royal Hospital, which performed a total of 25 BTKR. The incidence, Surgical and patient risk factors were recorded and analysed. Results. The incidence of AKI as defined by NICE guidelines following bilateral TKRs was 20%. 16% (4 patients) had stage 1 and 4% (1 patient) had stage 2 AKI. The mean change in Creatinine between pre- and post-operative blood tests was +19μmol/L. There was a strong significant correlation between CKD and AKI (r=0.75, P<0.05). Furthermore, a moderate correlation was found between higher BMI and pre-operative Charlson index and AKI. AKI did not have an effect on the length of inpatient stay with the mean inpatient length of stay for patients who had an AKI of 10 days compared to 11days for those who did not. All AKIs were resolved within 72 hours. There were no associated mortalities with AKI. Conclusion. The incidence of AKI following bilateral TKR was 20%. Pre-operative chronic kidney disease as well as having a higher BMI were identified as risk factors for developing AKI. Pre-operative CKD optimisation and careful adequate hydration intra-operatively should be considered in these patients. AKI was not associated with an increased length of stay or mortality in our study

Background. The current average tariff of a total knee replacement (TKR) is £5500. The approximate cost of each knee prosthesis is £2500. Therefore, length of patient stay (LOS) and the cost of patient rehabilitation influence the total costs significantly. Previous studies have shown a mean LOS of between 5 and 9.4 days for patients undergoing primary unilateral TKR but none looked at the factors influencing length of stay following bilateral primary total knee replacements (BTKR) at the same sitting. Objectives. To identify significant factors that influence the LOS following BTKR at the same sitting in a single centre in the UK. Methods. This was a retrospective single-centre study performed at the Princess Royal Hospital which performed a total of 25 BTKR. Surgical and patient factors that may influence LOS were recorded and analysed. Results. The mean LOS was 10 days with a median of 9 days. 64% were discharged within 10 days. Those staying longer were classified as long stayers. Being a female (0.65, p< 0.05), having a higher Charlson index (0.68, p< 0.05) and having a post-operative blood transfusion (0.59, p< 0.05) were the only significant factors that influenced LOS. Post-operative acute kidney injury (AKI), underlying diagnosis such as rheumatoid arthritis, BMI, age, worse pre-operative oxford knee scores and type of implant did not influence LOS. Conclusion. Factors influencing LOS following BTKR shown in our study seems to be the same as those influencing unilateral TKRs as identified in the literature. This should be taken into consideration when comparing unilateral versus bilateral TKR results as well as when planning a local arthroplasty service

Background. Direct anterior approach (DAA), total hip arthroplasty (THA, performed with the patient in the supine position, creates a unique opportunity to do bilateral THA under one anesthesia. Previous studies evaluating this option are limited by small sample size or lack of control group. The purpose of this study is to compare early clinical outcomes of simultaneous bilateral, unilateral and staged bilateral DAA-THA. Methods. Using an institutional registry database, we reviewed 3977 DAA-THA performed in 3334 patients at minimum 90-days follow up. A single surgeon performed all surgeries. Simultaneous bilateral DAA-THA group included 512 hips in 256 patients, unilateral DAA-THA group 2691 hips and staged bilateral DAA-THA group 774 hips in 387 patients. We reviewed 90-day postoperative complications, readmissions, length of stay, and rate of home discharge between all three groups. Results. There were no statistical differences in readmission (range 0.77–1.8%), postoperative clinical complications, and rate of home discharge (96.1–98.1%) between simultaneous bilateral, unilateral, or staged bilateral groups. The number of transfusions in the simultaneous bilateral group (9/256, 3.5%) was significantly higher than in the unilateral (24/2691, 0.89%, p=0.002) or the staged bilateral group (4/387, 1.0%, p=0.04). The total length of stay (LOS) in the simultaneous bilateral group (1.8 ± 0.8 days) was longer (p<0.001) than in the unilateral group (1.2 ± 1.0 days) but shorter (p<0.001) than the two added LOS in the staged bilateral group (2.8 ± 2.2 days). Conclusion. Our large cohort in a single surgeon case showed that simultaneous bilateral DAA-THA is comparable with unilateral or staged bilateral surgery in regards to postoperative clinical complications, readmission rate, and rate of home discharge but with an increased rate of transfusion. We believe that simultaneous bilateral DAA-THA is a reasonable and safe option in properly selected patients who require bilateral THA

Abstract. Introduction. In patients with bilateral unicompartmental knee osteoarthritis, simultaneous bilateral surgery is cost effective, with both patient-specific and wider socioeconomic benefits. There are concerns however regarding higher complication rates with bilateral knee surgery. This study compares simultaneous bilateral unicompartmental knee arthroplasty (UKA), to single side UKA in terms of complications and outcomes. Methodology. This is a retrospective case-control study of single side medial UKA patients (controls) and simultaneous bilateral medial UKA patients (cases). All patients underwent surgery between 2018 and 2022 by a single surgeon. The two cohorts were compared for perioperative blood loss (PBL), length of stay (LOS), complications (infections, blood clots, wound problems), Oxford Knee Score improvement (OKS) and revision surgery, with a follow-up period of up to 5 years. Results. 64 patients were followed up comprising 55 controls and 9 cases. Average length of stay for controls was 1.55 days and 2.22 days for cases (p=0.03). Average haemoglobin drop was 7.5g/l in controls and 12.8g/l in cases (p=0.04). The OKS improvement was comparable in both groups (p=0.95) with no complications and no revision surgery in either group. Conclusion. The statistically significant differences in PBL and LOS were not clinically relevant. There were no blood transfusions and postoperative haemoglobin was within normal range in more than 60% of cases. Simultaneous bilateral unicompartmental knee arthroplasty is a financially favourable and safe option for patients with bilateral knee medial unicompartmental osteoarthritis

A primary goal of revision Total Knee Arthroplasty (rTKA) is restoration of the Joint Line (JL) and Posterior Condylar Offsets (PCO). The presence of a native contralateral joint allows JL and PCO to be inferred in a way that could account for patient-specific anatomical variations more accurately than current techniques. This study assesses bilateral distal femoral symmetry in the context of defining targets for restoration of JL and PCO in rTKA. 566 pre-operative CTs for bilateral TKAs were segmented and landmarked by two engineers. Landmarks were taken on both femurs at the medial and lateral epicondyles, distal and posterior condyles and hip and femoral centres. These landmarks were used to calculate the distal and posterior offsets on the medial and lateral sides (MDO, MPO, LDO, LPO respectively), the lateral distal femoral angle (LDFA), TEA to PCA angle (TEAtoPCA) and anatomic to mechanical axis angle (AAtoMA). Mean bilateral differences in these measures were calculated and cases were categorised according to the amount of asymmetry. The database analysed included 54.9% (311) females with a mean population age of 68.8 (±7.8) years. The mean bilateral difference for each measure was: LDFA 1.4° (±1.0), TEAtoPCA 1.3° (±0.9), AAtoMA 0.5° (±0.5), MDO 1.4mm (±1.1), MPO 1.0mm (±0.8). The categorisation of asymmetry for each measure was: LDFA had 39.9% of cases with <1° bilateral difference and 92.4% with <3° bilateral difference, TEAtoPCA had 45.8% <1° and 96.6% <3°, AAtoMA had 85.7% <1° and 99.8% <3°, MDO had 46.2% <1mm and 90.3% <3mm, MPO had 57.0% <1mm and 97.9% <3mm. This study presents evidence supporting bilateral distal femoral symmetry. Using the contralateral anatomy to obtain estimates for JL and PCO in rTKA may result in improvements in intraoperative accuracy compared to current techniques and a more patient specific solution to operative planning

Introduction. This study reports on minimum 2 year follow up outcomes on functional and quality of life of patients after undergoing bilateral osseointegration in comparison to traditional socket prosthesis. Materials & Methods. This is a prospective pilot study of 35 patients, consisting of 30 males and 5 females, aged 22–66 (mean 36) years at surgery, with minimum two-year follow-up. Selection criteria were age over 18 years, bilateral amputees who had socket-related problems or were wheelchair-bound with short stumps and non-reconstructable limb pathology. Principle outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), Six Minute Walk Test (6MWT), Timed Up and Go (TUG), and K-levels. Adverse events were recorded including infection, revision surgery, fractures, and implant failures. Results. Comparisons were made using differences between the mean pre-operative and mean post-operative values for each outcome measure. Significant improvements in all validated outcome measures were observed. All patient who were wheelchair bound prior to the surgery were able to mobilise post operatively. The occurrence levels of adverse events, including the infection rate and revision rate within this patient cohort, were similar to other established trans-femoral osseointegration studies. Conclusions. These preliminary results indicate that osseointegration surgery is a safe and effective alternative treatment for bilateral amputees experiencing socket-related discomfort. Compared to the suboptimal outcomes of socket prostheses, osseointegration currently provides one of the best chances for any bilateral amputee to walk again and regain the ability to perform daily activities

Simultaneous bilateral total hip arthroplasty (THA) in patients with bilateral hip osteoarthritis is gradually becoming attractive, as it requires a single anesthesia and hospitalization. However, there are concerns about the potential complications following this surgical option. The purpose of this study is to compare the short-term major and minor complications and assess the readmission rate, between patients treated with same-day bilateral THA and those with staged procedures within a year. We retrospectively reviewed the charts of all patients with bilateral hip osteoarthritis that underwent simultaneous or staged (within a year) bilateral total THA in our institution, between 2016-2020. Preoperative patient variables between the two groups were compared using the 2-sample t-test for continuous variables, the Fisher's exact test for binary variables, or the chi-square test for multiple categorical variables. Similarly, differences in the 30-day major and minor complications and readmission rates were assessed. A logistic regression model was also developed to identify potential risk factors. A total of 160 patients (mean age: 64.3 years, SD: ±11.7) that underwent bilateral THA was identified. Seventy-nine patients were treated with simultaneous and eighty-one patients with staged procedures. There were no differences in terms of preoperative laboratory values, gender, age, Body Mass Index (BMI), or American Society of Anesthesiologists Scores (ASA) (p>0.05) between the two groups. Patients in the simultaneous group were more likely to receive general anesthesia (43% vs 9.9%, p0.05). After controlling for potential confounders, the multivariable logistic regression analysis showed similar odds of having a major (odds ratio 0.29, 95% confidence interval [0.30-2.88], p=0.29) or minor (odds ratio 1.714, 95% confidence interval [0.66-4.46], p=0.27) complication after simultaneous compared to staged bilateral THA. No differences in emergency department visits or readmission for reasons related to the procedure were recorded (p>0.05). This study shows that similar complication and readmission rates are expected after simultaneous and staged THAs. Simultaneous bilateral THA is a safe and effective procedure, that should be sought actively and counselled by surgeons, for patients that present with radiologic and clinical bilateral hip disease

The purpose of this study was to assess the variability in implant position between sides in patients who underwent staged, bilateral THA and whether variation from one side to the other affected patient-reported outcomes. A retrospective review was conducted on 207 patients who underwent staged, bilateral THA by the same surgeon from 2017–2022. Leg length, acetabular height, cup version, and coronal and sagittal stem angles were assessed radiographically and compared to the contralateral THA. Surgical approach and technology utilization were further assessed for their impact on variability. Linear regression was used to model the relationship between side-to-side variability and patient-reported outcome measures (PROMS). Between sides, mean radiographic leg length varied by 4.6mm (0.0–21.2), acetabular height varied by 3.3mm (0.0–13.7), anteversion varied by 8.2° (0.0 to 28.7), coronal stem alignment varied by 1.1° (0.0 to 6.9), and sagittal angulation varied by 2.3° (0.0 to 10.5). The anterior approach resulted in more variability in stem angle position in both the coronal (1.3° vs. 1.0°, p=0.036) and sagittal planes (2.8° vs. 2.0° p=0.012) compared to the posterior approach. The posterior approach generally led to more anteversion than the anterior approach. Use of robotics or navigation for acetabular positioning did not increase side-to-side variability in cup-related position or leg length. Despite considerable side-to-side variability, Hip dysfunction and osteoarthritis outcome scores (HOOS JR) were not affected by higher levels of position inconsistency. Staged, bilateral THA results in considerable variability in component position between sides. The anterior approach leads to more side-to-side variability in sagittal stem angle and cup anteversion than the posterior approach. Navigation and robotics do not improve the consistency of component position in bilateral THA. Variation in implant position was not associated with differences in PROMs, suggesting that despite variability, patients can tolerate these differences between sides

Total temporomandibular joint (TMJ) replacements reduce pain and improve quality of life in patients suffering from end-stage TMJ disorders, such as osteoarthritis and trauma. Jaw kinematics measurements following TMJ arthroplasty provide a basis for evaluating implant performance and jaw function. The aim of this study is to provide the first measurements of three-dimensional kinematics of the jaw in patients following unilateral and bilateral prosthetic TMJ surgeries. Jaw motion tracking experiments were performed on 7 healthy control participants, 3 unilateral and 1 bilateral TMJ replacement patients. Custom-made mouthpieces were manufactured for each participant's mandibular and maxillary teeth, with each supporting three retroreflective markers anterior to the participant's lip line. Participants performed 15 trials each of maximum jaw opening, lateral and protrusive movements. Marker trajectories were simultaneously measured using an optoelectronic tracking system. Laser scans taken of each dental plate, together with CT scans of each patient, were used to register the plate position to each participant's jaw geometry, allowing 3D condylar motion to be quantified from the marker trajectories. The maximum mouth opening capacity of joint replacement patients was comparable to healthy controls with average incisal inferior translations of 37.5mm, 38.4mm and 33.6mm for the controls, unilateral and bilateral joint replacement patients respectively. During mouth opening the maximum anterior translation of prosthetic condyles was 2.4mm, compared to 10.6mm for controls. Prosthetic condyles had limited anterior motion compared to natural condyles, in unilateral patients this resulted in asymmetric opening and protrusive movements and the capacity to laterally move their jaw towards their pathological side only. For the bilateral patient, protrusive and lateral jaw movement capacity was minimal. Total TMJ replacement surgery facilitates normal mouth opening capacity and lateral and inferior condylar movements but limits anterior condylar motion. This study provides future direction for TMJ implant design

Introduction: Lateral insufficiency fractures following total hip replacements have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. Materials and Methods: We present a 55 yr old lady, diagnosed with juvenile idiopathic arthritis aged 5 years, and had undergone bilateral total hip replacements at the age of 29 and 30 years and bilateral knee replacements aged 37 and 42 years. The right hip required revision of the cup 15 years later. The knees were in valgus and the left knee was extremely stiff flexing to just 5 degrees. She presented to us as an emergency with bilateral thigh pain with plain radiographs confirming bilateral peri-prosthetic fractures of the femur at the tip of well fixed femoral components. There had been no history of injury and her hips were functioning well up to this time. Results: The patient required revision of both hips to long stem un-cemented components, bypassing the fractures, and revision of both knees to stemed seni-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain free and mobile with walking aids. Discussion: Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding mal-alignment will avoid this complication. Bilateral peri-prosthetic stress fractures following total hip replacements have not been previously reported

To report the case of an asymptomatic simultaneous bilateral neck of femur fracture following vitamin D deficiency which was missed, misdiagnosed and treated for coexisting severe bilateral osteoarthritis knee. A male aged 62 years presented with severe osteoarthritis of both knee joints confining him to bed about eight weeks prior to presentation. The patient did not have any complaints pertaining to his hip joints/axial skeleton. Examination of the hip joints revealed only crepitus with absence of straight leg rising. Radiological survey showed bilateral displaced fracture neck of femur. He had elevated serum alkaline phosphatase; 119IU/L(N:39–117IU/L), decreased Serum 25 (OH) Vit D level;6.03ng/ml(N:7.6–75ng/ml), decreased spot urinary calcium;78mg/day(N:100–300mg/day) with normal serum calcium, phosphorus and highly raised parathormone levels;142.51pg/ml(N:12–72pg/ml). Tc-99 Bone scan showed increased radiotracer uptake in both the hip joints and knee joints. Bone Mineral Density was in favour of osteoporosis. Biopsy fromthe heads of both femurs also revealed osteoporosis. Bilateral staged total hip arthroplasty was done and he was put on Vitamin D replacement therapy. Patient was on regular monthly follow-up for intial one year and three monthly follow-up thereafter. At present with three year follow-up patient is community ambulant with a walking frame. Despite medical advice patient had denied total knee arthroplasty for osteoarthritis of his knee joints. Asymptomatic simultaneous bilateral neck of femur fracture is a rare injury and poses a diagnostic challenge to the treating orthopaedic surgeon with its bizarre clinical picture. Similar presentation of metabolic bone disease can be easily missed without a proper screening, keeping in mind a high index of suspicion for the above disorders. Besides proper clinical examination of both hip and knee joint should be performed in patients presenting with bilateral knee pain. A good functional outcome may be achieved with prompt surgical intervention and medical treatment

Intro: Quadriceps rupture following total knee arthroplasty is a devastating injury. Early operative repair is necessary to maintain the integrity of the extensor. Postoperative rehabilitation usually involves a prolonged period of immobilisation to allow the repair to consolidate. This immobilisation can cause irreversible stiffness in the patient with a total knee replacement. We present a method of rehabilitation to allow early range of motion. Case Report: A 57 year old gentleman presented with bilateral tri-compartmental osteoarthritis, he had no other significant medical history. Bilateral synchronous total knee replacements were performed and the early post operative was unremarkable. The patient fell whilst mobilising indoors at home during the fifth post operative week and sustained rapid hyperflexion injures to both knees. Ultrasound scans of the knees demonstrated bilateral discontinuities of the quadriceps mechanisms and a large fluid collection filling the defect. The patient returned to the operating where a direct repair was achieved. Post operatively the patient was rested in bilateral cylinder casts until the sutures were removed at two weeks. For two week periods the knees were then mobilised in a hinged cast brace allowing 0–30, 0–60 and 0–90 degrees making the total time in cast 8 weeks. At the time of removal of the casts the patient had 110 degrees of flexion in the right leg and 85 degrees of flexion in the left. At six months postoperatively the patient flexes freely to over 100 degrees. Conclusion: Bilateral quadriceps ruptures in a relatively young patient can be managed with early repair and an aggressive rehabilitation regime. This case suggests that is possible to achieve a satisfactory outcome although the input required is significant

Introduction. Recurrent patellar dislocation is often reported in bilateral knees in young active individuals. The medial patellofemoral ligament (MPFL) tear is the attributable cause behind many of them and warrants reconstruction of the ligament to stabilize the patellofemoral joint. Besides, trochleoplasty and Fulkerson's osteotomy are some other procedures that are performed to treat this problem. This study aimed to compare the clinical and functional outcomes in a cohort of patients with single-stage bilateral realignment procedures vs staged procedures. Methods. It was a retrospective matched cohort study with prospectively collected data. A total of 36 patients (mean age-26.9 years, range 13 years to 47 years) with recurrent patellar dislocations, who underwent a surgical correction in both the knees, were divided into two matched groups (age, sex, follow-up, and type of procedure). Among them, 18 patients had surgeries in one knee done at least six months later than the other knee. The remaining 18 patients had surgical interventions for both knees done in a single stage. Lysholm, Kujala, Tegner, and subjective knee scores of both groups were compared and analyzed. The rate of complications and return to the theatre were noted in both groups. Results. With a mean follow-up of 7.3 years (2.0 years to 12.3 years), there was a significant improvement in PROMS observed in both the groups (p<0.05). No significant difference could be found between the two groups in terms of the Lysholm, Kujala, and subjective knee scores (p> 0.05). The rate of complication and the re-operation rate was comparable in both the groups (p>0.05). Conclusion. The outcomes of staged vs simultaneous surgeries for bilateral patellofemoral instability are comparable. Our results indicate that simultaneous bilateral surgical correction is safe. This can potentially be an option to reduce the surgical cost and perioperative morbidity. However, careful selection of cases, choice of the patient, and the scope of rehabilitation facilities are some of the other factors that should be considered

Abstract. Objectives. Although hip replacement and resurfacing procedures both aim to restore mobility, improve joint function, and relieve pain, it is unclear how each differ in terms of gait mechanics and if they are affected by varying walking speeds. We compared limb symmetry and ground reaction force (GRF) profiles between bilateral total hip arthroplasty patients (THA), bilateral hip resurfacing arthroplasty patients (HRA), and healthy control participants (CON) during level-treadmill walking at different speeds. Methods. Bilateral THA and bilateral HRA patients (nTHA = 15; nHRA = 15; postoperative 12–18 months), and age-, mass-, and height-matched CON participants (nCON = 20) underwent gait analysis on an instrumented treadmill. Walking trials started at 4 km/h and increased in 0.5 km/h increments until top walking speed (TWS) was achieved. Gait symmetry index (SI = 0% for symmetry) was assessed between limbs during weight-acceptance, mid-stance and push-off phases of gait; and vertical GRFs were captured for the normalised stance phase using statistical parametric mapping (SPM; CI = 95%). Results. THA had a significantly lower TWS (6.51 ± 0.06 km/h) compared to HRA (7.09 ± 0.07 km/h, p = 0.01) and CON (7.15 km/h ± 0.06, p = 0.02). There were no SI differences between groups nor between walking speeds (SI < 5%). There were no GRF differences between groups at slower walking speeds (4.0–5.0 km/h). However, at 5.5 and 6 km/h, THA had lower GRF at the push-off phase (0.88 ± 0.09 N/BW), compared to HRA (1.06 ± 0.08 N/BW, p = 0.01) and CON (1.04 ± 0.02 N/BW, p = 0.01). Conclusions. The main finding was that HRA patients demonstrated restored gait function and similar walking profiles to CON participants at any speed. With a diverging gait profile, walking speeds over 5.5 km/h provided a functional challenge for THA patients

In recent years, there has been increasing interest in the use of simultaneous hip arthroplasty compared to staged procedures in patients with bilateral pathology. The aim of this study was to compare simultaneous and staged hip arthroplasty in patients with bilateral pathology by assessing the transfusion rate, postoperative hemoglobin drop, length of stay (LOS), in-hospital complications, 30-days readmissions, leg length difference and early functional outcome. We conducted a retrospective cohort study that included all patients who were undergoing primary total hip arthroplasty (THA) by a single surgeon in a high-volume arthroplasty center between 2015 and 2020 as simultaneous or staged procedures. Staged bilateral arthroplasties were performed within 12 months and were stratified by the time between procedures. Data was acquired through the electronic files at the Orthopädische Chirurgie München (OCM). For functional outcome we compared the ability of the patients to walk independently on the ward and the ability to walk a set of stairs alone which was recorded daily by the attending physiotherapist. In total n=290 patients were assessed for eligibility and included in this study. One hundred and thirty eight patients were allocated to the staged arthroplasty group. The second staged procedure was performed within 12 months of the first procedure. One hundred and fifty two patients were allocated to the simultaneous arthroplasty group. No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: There was no significant difference in transfusion rate or complication rate (p=0.1147). In both groups the transfusion rate was actually 0%. Secondarily, no statistically significant difference was found between the postoperative hemoglobin drop (p=0.1147) and the functional outcome (p=0.7249), nor the length of stay (LOS) (p=: 0.6415), as well as the 30 days readmission rate between both groups. No difference was found in leg length in the simultaneous group. The OR time in the simultaneous group ranged from 62min to 111min with an average of 77min. No surgery exceeded a 120min window. We observed no significant differences in transfusion rate, in hospital complications, as well as readmission rate between both groups. The early functional outcome showed no significant difference in mobility. Simultaneous hip arthroplasty is as safe as a staged procedure, with no higher risk for the patient, in a specialized high volume center with a specialized surgeon and an adequate team. Level of evidence: Level IV

It is estimated that approximately 3.1 – 7.7% of the general population suffers from primary osteoarthritis of the hip, with up to 42% of these cases being bilateral. The odds of undergoing a contralateral THA after index unilateral THA range from 16–85%. Up to 20% of these patients have the contralateral THA within 5 years. For this patient population, simultaneous bilateral THA may be an appealing option but it remains controversial. Proponents of bilateral simultaneous THA cite advantages such as a single anesthetic exposure, overall shorter length of hospital stay, quicker recovery, earlier return to function, less time off of work, and potential economic advantages. Only recently has there been more data emerging on patients undergoing simultaneous bilateral THA through the direct anterior approach (DAA). The DAA has the distinct advantage of supine positioning that facilitates easy exposure to both hips without the need to reposition the patient onto a fresh surgical incision while performing the second operation. Recent publications suggest that bilateral simultaneous DAA is a safe procedure and may have economic benefits as well. At our institution between 2010 and 2016, a consecutive series of 105 patients (210 hips) undergoing simultaneous bilateral DAA THA and a matched group of 217 patients undergoing unilateral DAA THA by the same surgeon at a single institution were reviewed. The two groups were matched by gender, age, body mass index and date of surgery. There were no significant differences between the two groups in terms of early complications. There were 2 complications in the unilateral group that were intraoperative nondisplaced calcar fractures that were treated with a single cerclage cable and 50% weight bearing for four weeks. There were 6 in-hospital systemic complications in the unilateral group compared to 7 in the bilateral group (p = 0.129). In-hospital systemic complications were similar between the two groups and included urinary retention, cardiopulmonary abnormalities, alcohol withdrawal, and nausea / vomiting. There were a total of 14 30-day follow-up hip-related complications in the unilateral group compared to 5 in the bilateral group (p = 0.06) These complications were similar between the two groups and included wound healing issues, tendinitis / bursitis, deep infection, nerve palsy, stem subsidence, and instability. Intraoperative estimated blood loss (EBL) was 360cc in the unilateral group compared to 555cc in the bilateral group (p < 0.001). The bilateral group had lower postoperative day one (POD1) hemoglobin (9.5 g/dl vs. 10.2 g/dl; p < 0.001). Four percent of unilateral patients required blood transfusion compared to 11% in the bilateral group. There were significant differences between the two groups in terms of distance ambulated on POD1 and length of stay (LOS). On average, the unilateral patients walked 235 feet on POD1 compared to 182 feet for the bilateral patients (p < 0.001). Length of stay was significantly longer in the bilateral group (1.95 days vs. 1.12 days; p < 0.001). All 322 patients involved in the study were discharged to home except for a single patient in the bilateral group who was discharged to a skilled nursing facility. In conclusion, we found no difference in in-hospital or 30-day complication rates when comparing the simultaneous bilateral group to the unilateral group. The main difference when compared to unilateral surgery is increased blood loss yet this did not directly result in specific complications. Simultaneous bilateral DAA THA can be performed safely and without an unacceptably high perioperative complication rate

A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH. Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines. Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline. The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO

Simultaneous bilateral total hip arthroplasties (THAs) present unique and unwarranted dangers to the patient and surgeon alike. These include a significantly increased risk of blood transfusion (up to 50% in contemporary series even with the use of tranexamic acid), longer operative times, longer length of stays, and higher mortality rates in patients with minimal risk factors (age > 75 years, rheumatoid arthritis, higher ASA class, and/or male sex). This is even in light of the fact that the vast majority of literature has a substantial selection bias in which only the healthiest, youngest, non-obese, and most motivated patients are included. Traditionally, simultaneous bilateral THAs were completed in the lateral decubitus position. This required the surgeon and surgical team to reposition the patient onto a fresh wound, as well as additional prepping and draping. To mitigate these additional limitations of simultaneous bilateral THAs, there has been a recent trend towards utilizing the direct anterior approach. However, this particular approach presents its own unique set of complications such as an increased risk of periprosthetic femoral fracture and early femoral failure, an increased risk of impaired wound healing (particularly in obese patients), potential injury to the lateral femoral cutaneous nerve with subsequent neurogenic pain, and traction-related neurologic injuries. When compounded with the risks of simultaneous bilateral THAs, the complication profile becomes prohibitive for an elective procedure with an otherwise very low morbidity

Purpose. To establish if the subjective features of both bilateral leg pain and sexual dysfunction are presenting features in cauda equina syndrome (CES). Background. There appears to be conflicting expert opinion ‘red flag’ symptoms in the context of CES with many experts basing clinical decisions on the objective clinical findings only. Bilateral radiculopathy has been suggested as a possible sign of suspected CES, although a consensus statement by BASS and SBNS makes no reference to either this or sexual dysfunction. However, bilateral leg pain is included in the NICE clinical knowledge summary and sexual dysfunction is highlighted within CES guidance by the American Association of Neurological Surgeons. Methods. The clinical documentation of patients undergoing urgent magnetic resonance imaging (MR) due to clinical suspicion of cauda equina syndrome (CES) was reviewed over 12 months. Patients questioned regarding sexual function were included in this retrospective analysis (n=179), along with those with bilateral leg pain (n=294). Patients with confirmed cauda equina compression (CES +ve) were compared to those without (CES -ve). A logistic regression was applied to find the odds ratio. Results. In CES +ve 37.5% had sexual dysfunction, 48% had bilateral leg pain. CES –ve 14% had sexual dysfunction, 27% bilateral leg pain. Both significant to p=0.015 with an odds ratio of 3.6 and 2.5 respectively. Conclusions. Both sexual dysfunction and bilateral leg pain do appear to be ‘red flags’ for CES and should therefore be asked in the ED to aid clinical reasoning when suspecting this diagnosis. No conflicts of interest. No funding obtained

Introduction. Despite several studies, controversies prevailed about the rate of complications following one-stage and two-stage bilateral total hip arthroplasty (THA). In current prospective study, we compared the complications and functional outcomes of one-stage and two-stage procedures. Methods. One hundred and eighty patients (ASA class I or II) with bilateral hip osteoarthritis were assigned randomly to two equal groups. Two groups were matched in term of age and sex. All of the surgeries were performed through the Harding approach using uncemented implants. In two-stage procedures, surgeries were performed with 6 months to one year interval. All patients were evaluated one year postoperatively. Results. The Harris hip score averaged 84.1±12.6 and 82.6±15.3 in one-stage and two-stage groups, respectively (p=0.528). The hospital stay was significantly longer in two-stage group (9.8±1.1 versus 4.9±0.8 days). The cumulative hemoglobin drop and number of transfused blood units were the same. One patient in each group developed symptomatic deep venous thrombosis and managed successfully. There was no patient with perioperative death, pulmonary embolism, infection, dislocation, periprosthetic fracture or heterotrophic ossification. No patient required reoperation. Two patients in one-stage group developed unilateral temporary peroneal nerve palsy resolved after 3 and 4 months. Conclusion. The current study showed that one-stage bilateral THA can be used successfully for patients who require bilateral hip arthroplasty without increased rate of complications. The functional and clinical outcomes are comparable and hospital stay is significantly shorter. However, the authors recommend to perform one-stage bilateral THA for healthy patients with ASA class I or II