The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome. Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score. Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001). Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively

Young patients undergoing THA or hip used. HOS and iHOT33 have demonstrated to be useful in hip preservation surgery but never used in THA. The aim of the study was to evaluate long-term clinical outcomes with HOS and iHOT33 in hip arthroscopy and THA. We conducted a retrospective study with prospective data collection of 118 consecutive young patients (<65 y.o.) between 2008 to 2012 who underwent hip arthroscopy or THA. The mean follow-up was 12.05 years. All surgeries were done by the same senior surgeon. PROMs used were iHOT-33 and HOS preoperatively, at one year and 10 years. SPSS Statistics Grad Pack 28.0 software was used for statistical analysis. Arthroscopy Group (57 patients): Mean age 35.36 years. 55.93% were male. iHOT33 mean differential improvement was 24.43 at 1 year, 70,17% exceed MCID and 49,1% SCB. HOS mean differential improvement was 16.26 at one year. 54,38 % patients exceed MCID and 49,36% SCB. At 10 years, iHOT33 mean differential improvement was 14,36 and 12.56 for HOS. Regarding complications, 3 patients underwent THA (5.26%) and 10 (17.54%) continued with groin pain. THA Group (61 patients): Mean age 52,54 years. 55.73% were male. Cementless THA was used in all patients with ceramic on ceramic used in 77%. iHOT33 mean differential improvement was 41,57 at 1 year. 95,08% patients exceed MCID and 85,25% SCB. HOS mean differential improvement was 16.57 points at one year. 85,25% patients exceed MCID and 81,97% SCB. At 10 years, iHOT33 mean differential improvement was 20,15 and 14.12 for HOS. Regarding complications, 1 patient underwent DAIR for infection (1.64%) and 1 dislocation with close reduction (1.64%). iHOT33 or HOS scores should be considered to be used in young active patients after hip preserving surgery or THA, with more predictable results at long-term in THA group

Aims. The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

The challenges faced by hip surgeons have changed over the last decade. Historically, fixation, polyethylene wear, osteolysis, loosening and failure to osseointegrate dominated the discussions at hip surgery meetings. With the introduction of highly crosslinked polyethylene, wear and osteolysis are currently not significant issues. Improved surgical technique has resulted in a high rate of osseointegration and once fixed, loosening of cementless components is rare. In this session, we will focus on issues that orthopaedic surgeons performing hip surgery routinely face including bearing couples in the young active patient, implant choices in the dysplastic hip and osteoporotic femur, evaluation and management of the unstable hip and differential diagnosis of the painful THR

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes. Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection. The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window. Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure. On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig). This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy.

55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used.

As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible.

Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time.

Fracture of contemporary femoral stems is a rare occurrence. Earlier THR stems failed due to design issues or post manufacturing heat treatments that weakened the core metal. Our group identified and analyzed 4 contemporary fractured femoral stems after revision surgery in which electrochemical welds contributed to the failure.

All four stems were proximally porous coated titanium alloy components. All failures occurred in the neck region post revision surgery in an acetabular cup exchange. All were men and obese. The fractures occurred at an average of 3.6 years post THR redo (range, 1.0–6.5 years) and 8.3 years post index surgery (range, 5.5–12.0 years). To demonstrate the effect of electrocautery on retained femoral stems following revision surgery, we applied intermittent electrosurgical currents at three intensities (30, 60, 90 watts) to the polished neck surface of a titanium alloy stem under dry conditions.

At all power settings, visible discoloration and damage to the polished neck surface was observed. The localized patterns and altered metal surface features exhibited were like the electrosurgically-induced damage priorly reported.

The neck regions of all components studied displayed extensive mechanical and/or electrocautery damage in the area of fracture initiation. The use of mechanical instruments and electrocautery was documented to remove tissues in all 4 cases.

The combination of mechanical and electrocautery damage to the femoral neck and stem served as an initiation point and stress riser for subsequent fractures. The electrocautery and mechanical damage across the fracture site observed occurred iatrogenically during revision surgery. The notch effect, particularly in titanium alloys, due to mechanical and/or electrocautery damage, further reduced the fatigue strength at the fractured femoral necks. While electrocautery and mechanical dissection is often required during revision THA, these failures highlight the need for caution during this step of the procedure in cases where the femoral stem is retained.

The challenges faced by hip surgeons have changed over the last decade. Historically, fixation, polyethylene wear, osteolysis, loosening and failure to osseointegrate dominated the discussions at hip surgery meetings. With the introduction of highly crosslinked polyethylene, wear and osteolysis are currently not significant issues. Improved surgical technique has resulted in a high rate of osseointegration and once fixed, loosening of cementless components is rare. In this section, we will focus on issues that orthopaedic surgeons performing hip surgery routinely face including bearing couples in the young active patient, implant choices in the dysplastic hip and osteoporotic femur, evaluation and management of the unstable hip and differential diagnosis of the painful THR

The disadvantages of hip spica casts following hip surgery for cerebral palsy include fractures, plaster sores, soiling and general inconvenience. In this series, 56 hips in 31 children aged 4 to 16 years (mean 8) were treated for hip displacement in keeping with the recommendations of others (eg Miller et al 1997) between 2005 and 2008 by one consultant. There were 29 open reductions for a Reimer's migration index (RMI) greater than 50%. A blade plate was used for the femoral osteotomy, and an acetabuloplasty was performed for 22 hips. No casting or immobilisation of any sort was used. The average length of stay was 5 days. The results at 5 the year follow-up were chosen so that all patients were at the same stage. The average RMI pre-operatively for displaced hips was 76.9 +/− 21.3. At follow-up it was 18.8 +/− 19.7. 18 patients had pain prior to hip surgery; 6 had pain during follow-up, and 4 of these responded to removal of metal; and one required a proximal femoral resection. There were 3 complications: one re-dislocation in the immediate post-operative period, one mal-union because the blade plate cut out; and one of the three walking children fractured below the blade plate 2 ½ months after surgery. There were no infections. The radiographic and clinical outcomes of hip reconstruction without hip spica immobilisation are good, reproducible and long-lasting. The child may be nursed free post-operatively and discharged in his or her own chair. As a result of studying these patients, since 2009 we have introduced locking plates for better fixation, and pre- and post-operative Paediatric Pain Profiles and CPCHILD questionnaires

Objective of the study is to determine to what extent patients experience more limitations 1–5 years after revision total hip arthroplasty (THA) compared to patients after primary THA, and if this is accompanied by a reduction in physical activity behavior. Five hundred and six patients were included: 372 primary and 134 revision THA. Questionnaires were used to measure limitations and physical activity. Linear regression analysis showed that patients after revision surgery report significantly more, clinically relevant limitations compared with primary THA patients, but did not show a significant difference in mean total minutes of physical activity per week. Physical activity behavior appeared to be similar for primary and revision THA patients. The results stress the importance of determining different aspects of recovery after THA.

The aim of this study is to evaluate which patients, if any, can be eligible for a rapid discharge from Hip Surgery Department at 24 hours after primary total hip arthroplasty. Methods In this retrospective clinical trial were included all patients undergone to primary total hip arthroplasty in our Hip Surgery Department from January to June 2004. Exclusion criteria were preoperative anaemia (Hb< 12g/dL), coagulation disease, hip fracture, previous hip surgery and not-weight bearing indication after operation. All patients received an uncemented total hip arthroplasty with posterior surgical approach in regional anaesthesia. All patients had the same post-operative (PO) management including analgesia, prevention of DVT, immediate muscle exercises and physiotherapy for walking on crutches starting on the second PO day. The clinical history, vital parameters, haemoglobin (Hb) value before surgery and for 5 days PO, adverse events like luxation and transfusion were registered. For the statistical evaluation were used the paired “t-test” with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant. Results 234 patients (mean age 65y; range 21–91y) were admitted to the study. 128 women and 106 men. For the blood loss evaluation, the presence of no homogeneous preoperative Hb lead us to analyse the decrease rate of preoperative Hb (DRPH). The mean DRPH was: 22,47% at 1dayPO; 25,09% at 2 daysPO; 22,83% at 3 daysPO; 26,76% at 5 daysPO. For the safety evaluation were considered the incidence of transfusions (limit was set at Hb< 8g/dL) that were related to the preoperative Hb and the age. The transfusion incidence for each preoperative Hb (PrHb) value was: 14% (7/49) for 12< PrHb< 13; 11% (6/53) for 13< PrHb< 14; 11% (5/43) for 14< PrHb< 15; 7% (2/26) for 15< PrHb< 16g/dL. For age under 70y and PrHb> 14g/dL there were the lowest transfusion incidence: 3% (2/41). No adverse events were able to prevent patients from going to Rehabilitation Unit. All patients were able to do their own physiotherapical programme. Pain during physiotherapy was low (mean value of VAS = 3,47). Discussion During the last decade the improvement of anaesthesiologic and surgical technique with minimally invasive soft tissue approach (small incision and little muscular sacrifice) lead to a significant reduction in adverse events after primary total hip arthroplasty. So the relative safety of this surgery justifies the growing importance of intensive rehabilitation and fast recovery. This study shows the safety of a rapid discharge from the Hip Surgery Department. The main adverse event after 24 hours PO is the necessity of blood transfusions, but the incidence rate of only 3%, like in patients with preoperative Hb> 14g/dL and age below 70 years, is not a problem for the physicians of the Rehabilitation Unit. Conclusion This study confirms the possibility to perform a safe One Day Hip Surgery by an accurate selection of the patient

Introduction: With an ever-increasing elderly population the rise in primary total hip replacement is inevitable. This translates into a comparative rise in revision hip surgery. We performed an observational study to determine current revision hip surgical practices in one UK region. Methods: We utilized a regional hip register (Trent Arthroplasty Audit Group (TAAG)) to review current revision hip surgical practice in our region. 136 surgeons in 21 different hospitals, covering a population of 6.2 million, contribute to the register. We analysed completed data forms to produce the following results. Results: 875 revision THRs performed between 2000 and 2002 were identified. 54% were female, with a mean age of 70 (range 26–97). 45 different femoral stems requiring revision were identified. Reasons for revision were aseptic loosening of both components (23%), cup alone (24%), stem alone (17%), infection (14%), recurrent dislocation (10%), periprosthetic fracture (5%) and acetabular erosion (3%). Over 25 different femoral stems and over 30 different acetabular components were utilised by surgeons. In 70% of cases the femoral and acetabular components were made by different manufacturers. Bone graft was used in approximately 50% of cases. 90% of centres contributing to TAAG perform revision hip surgery. 24% of all revision THRs were performed by surgeons performing 5 or less per year. Only 40% of revision THRs were performed by ‘revision surgeons’ performing > 20 per year. Conclusions: It is evident the majority of centres, both teaching and DGH, in our region regularly perform revision hip surgery, with up to a quarter performed by non-revision specialists. With increasing numbers of prostheses available, high numbers of component mismatch use, and the inevitable increase in future need for revision hip surgery, is the occasional revision surgeon compromising patient care? Will this have future medico-legal consequences?

Introduction: Revision hip surgery with impaction allografting is an attractive operation because of its potential to restore lost bone stock. Several authors have reported variable results, some disastrous, with massive subsidence of the stem. Aim: To study the radiographic and clinical results of impaction allografting for revision hip surgery done in our department. Materials and methods: 49 patients (50 hips) underwent revision hip surgery using the impaction allografting technique and the Exeter stem between the years 1993 to 1997. The average follow up was 6 years (range 4 – 9 years). Results: There were 7 dislocations. One patient had early painful subsidence of the stem requiring revision. 44 (90%) hips had subsidence of stem equal to or less than 5 mm at last follow up. 5 (10%) had subsidence ranging from 6 to 7 mm. Hip function was uniformly good and patients were extremely satisfied. Conclusion: Revision hip surgery with impaction allografting is an effective operation. With meticulous attention to this technique, revision hip surgery need not necessarily be associated with inferior outcomes compared to primary hip surgery

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Significant proximal femoral bone deficiency in revision hip surgery poses a considerable challenge, especially as revision hip surgery is increasing in prevalence. Many femoral prosthetic devices, which compensate for this bone loss, are available to surgeons but ideally one wants to restore viable proximal bone stock. The Oxford Universal Hip (OUH) has been designed and modified with these challenges in mind. This is atrimodular, non-locking device that allows for some rotation and subsidence in the cement. Load transfer occurs at the proximal wedge, thus avoiding proximal stress shielding. The OUH has been used extensively in both primary and revision hip surgery and is particularly useful when used in conjunction with proximal impaction bone grafting. The main aim of this study was to determine the clinical outcome of the patients. The viability and survivorship of the impacted bone graft was assessed in order to give some indication of adequate perfusion of the incorporated bone grafting. Between 1999 and 2002 the OUH, in combination with proximal impaction bone grafting, was implanted in 72 hip revisions in 69 patients. All patients were clinically evaluated using the Oxford Hip score. Histological samples of impacted bone grafting were analysed by a pathologist 2 years after implantation to assess viability and perfusion of the impacted bone graft. The Oxford Hip Score improved from a pre-operative to a post-operative score of 45 (26–58) to 24.3 (12–43) respectively (p< 0.001). The mean follow up time was 32.7 months and in that time there were no re-revisions for aseptic loosening. Histology demonstrated viable bone stock in the proximal femur where bone grafting had been impacted 2 years previously. The OUH is a versatile hip prosthesis for use in revision hip arthroplasty and is especially well suited to proximal impaction bone grafting where it is possible to restore viable bone stock

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England. The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action. A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed. The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465. Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims

Background. Revision total hip arthroplasty is a technically demanding procedure and especially removing a well fixed femoral stem is a challenge for revision surgeons. There are various types of trochanteric osteotomies used during revision surgery; extended trochanteric osteotomy (ETO) is being more popular. Aim. The aim of this study is to look at types of trochanteric osteotomy used during the revision surgery. We looked at the success and failure of these osteotomies. Failure of the osteotomy is defined by complete pull off by the hip abductors resulting in osteotomy fragment is no contact with the femur. We sought to assess the time to healing of osteotomy and number of cables used. Methods. We retrospectively reviewed the hospital theatre database and identified 97 patients who underwent revision hip surgery from June 2008 to December 2015. Among these 35 patients (36% of patients) had trochanteric osteotomy for either extraction of femoral stem or removal of cemented mantle. Results. Most common cause of revision was aseptic loosening in 22 cases (62%) followed by peri prosthetic fracture 6 cases (17%), 1. st. stage of revision surgery in infective cause in 4 cases (11%). Depending on the length of the osteotomy performed we divided the patients into two groups. The first group had osteotomy just around the greater trochanter, which is called short trochanteric osteotomy group and the second group had extended trochanteric osteotomy where the osteotomy length is at least of 15cms and preserving the vastus lateralis attachment to the osteotomy. 7 patients had short trochanteric osteotomy and remaining 28 patients had extended trochanteric osteotomy. In the short trochanteric osteotomy group had 4 out of 6 patients had failure of the osteotomy repair. In extended trochanteric osteotomy group, there was one immediate failure and another one had delayed trochanteric pull off out of 28 patients (93% success rate). The time taken for the osteotomy to heal in short trochanteric osteotomy group was 8 months where as in the extended osteotomy group it was 5 months. The mean number of cables used was 3 in both groups. There was no subsidence seen during the post op follow up in either group. Conclusion. Our study concluded that ETO is a safe procedure with a low complication rate rather than short trochanteric osteotomy. Implications. Awareness about the biomechanics of ETO and its indications can make ETO an important tool in the revision surgeon's armamentarium

Introduction: Revision hip surgery is likely to become more frequent with the continued use of cemented primary hip prostheses. Primitive stem cells from bone marrow become osteocytes in the presence of hydroxyapatite ceramic (HAC). Consequently there is osseointegration of an HAC surface in bleeding cancellous bone/marrow. However, damaged bone in the revision situation does not provide the necessary stem cells for osseointegration. Revision surgery using standard length (150mm) HA coated stems is not always satisfactory. Using a 200 mm stem will extend the operating field into fresh, undamaged cancellous bone and marrow. Method: Since 1988 more than 2600 HAC hips have been implanted for primary and revision hip cases. This includes 148 revisions. The continued use of primary HAC hips has reduced the necessity for revision hip surgery. There is a dwindling population of cemented, loosening hips requiring revision. Patients are assessed radiologically and using the Harris Hip Score (HHS) pre. and post-operatively on an annual basis. Results: Since 1991 the longer 200mm stems have been used in 73 cases. The results have been rewarding. The system works with improved HHS. Defects from debris disease fill in and stems are seen to bond to the host bone particularly at the tip. There have been no prosthetic fractures. Only one case has needed re-revision when a stem remained un-bonded in the presence of a transverse femoral fracture. Two other stems are probably not bonded. This represents 4% failure. Discussion: HA bonding is a successful system of fixation in primary hip arthroplasty. Using a 200mm stem in revision cases allows virgin bone marrow to provide the necessary stem cells for fixation. These longer HA coated stems should be used in revision surgery

The aim of this study is to evaluate techniques which may reduce intra and Post-Operative (PO) bleeding in hip surgery. Methods: In this prospective study, from 9/2005 to 6/2006, we evaluated Blood Loss (BL) after primary total hip arthroplasty. Exclusion criteria were anti-coagulant drugs not discontinued 10 days before surgery and patients whose condition precluded weight bearing PO. We included total hip arthroplasty with posterior surgical approach, spinal anaesthesia, hypotensive surgery and peri-operative blood salvage (Ortho PAS, Euroset). When appropriate, the Mini-Invasive Approach (MIA) was used. In a different sub-set of patients, including some of the minimally invasive patients, a new bipolar Radio-Frequency sealer (TissueLink) was used. The PO program had pain control, LMWH for prevention of DVT, exercise from the day of surgery and walking on crutches from the next day. We analysed: blood loss after surgery and for 3 days; haemoglobin values (g/dL) before surgery and for 5 days PO; thigh circumference pre-op and at 5 days and adverse events such as transfusions and luxation. For the statistical evaluation the paired “t-test” was used, with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant. Results: 324 patients (mean age 68; range 23 to 89; 179 F & 145 M) were admitted to the study. Mean BL was 305ml intraoperative, 501ml at 6 hours PO, 304ml at 1day PO, 132ml at 2 days PO and trace at 3 days. Rather than simple unit measures, we analyzed the Percent Change in Hb from preoperative levels (%CHb). The patients had a mean %CHb of 23,09% at 1day PO, 26,67% at 2 days PO, 28,13% at 3 days and 29,07% at 5 days. Transfusion rates (TR; trigger set at Hb< 8g/dL) were related to the preoperative Hb and age. Overall TR was 15% (51/324), the prevalence of homologous transfusion was 7% (24/324). The TR for each Hb value: 21% (15/69) for Hb=12–13, 20% (20/98) for Hb=13–14, 17% (15/88) for Hb=14–15 and 5% (1/29) for Hb=15–16. The mean value of pain during rehabilitation was 3,11(VAS). MIA (53/324) was associated with reduced BL (mean %CHb at 1st day PO 19.12; TR 9%), but with high variability. The use of bipolar sealer (58/324) was associated with a significant reduction in overall BL (mean %CHb at 1st day PO 15.83; TR 5%) as well as a reduction of thigh swelling (37%) and of mean rehabilitation pain (30%; VAS=2.15). Discussion: Reduced blood loss, reduced post-operative pain and a faster functional resumption are obtained with both the minimally invasive approach and the TissueLink sealer approach. In addition, MIA provides muscle preservation and the use of the TissueLink sealer provides reduced post-operative swelling. Conclusion: This study shows that both the minimally invasive surgical approach and the use of an irrigated RF bipolar sealer can lead to reduced blood loss and faster functional resumption following hip surgery

Postoperative dislocations are known to be a big problem in revision surgery. In literature dislocation rates vary from 4.8% to 33% after previous surgery. In revision surgery, impingement of the implant components, the capsular and soft tissue release, muscular weakness and greater trochanter problems can give additional instability. The reason for revision is important, where instability, infection and tumour cases will lead to a higher percentage of dislocations. The use of big metal heads on polyethylene should be avoided because of the higher volumetric wear. With the new developments of metal-on-metal hip resurfacing and the production of big modular metal heads, the metal-on-metal bearing should guarantee a low-wear result without osteolysis. Between November 2000 and December 2003 45 patients requiring a revision were treated with a Birmingham Hip Resurfacing cup (MMT, UK) and a big metal-on-metal modular head. All surgery was done with a posterolateral approach. Cup sizes range from 44 to 66 mm, head sizes range from 38 to 58 mm. The head sizes most often used were 58 mm, 54 mm and 50 mm. All patients were prospective followed using the Orthowave software (CRDA France). In this series of 45 revisions (mean age 56.17) with large modular heads we encountered 2 dislocations, which give us a dislocation rate of 4.4%. One of these dislocations became recurrent and was revised to a full-constrained acetabular component. Our own dislocation rate in revision hip surgery is 13% (21/159) in the anterolateral approach. Dislocations using the posterolateral approach increased this percentage to 14.8% (21/141). Taking in account that 31% of the causes of revision were infection and recurrent dislocation, this trial demonstrates that large diameter ball heads give beside a better range of movement also a statistically proven reduction in the dislocation rate in revision hip surgery