Aims. Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome. Cite this article: Bone Jt Open 2024;5(9):729–735

Aims

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.

We aimed to examine outcomes between displaced femoral neck fracture (FNF) patients managed with total hip arthroplasty (THA) or hemi-arthroplasty (HA) via the anterolateral vs. posterior approach. We used data from the HEALTH trial (1,441 patients aged ≥50 with displaced FNFs randomized to THA vs. HA). We calculated each patient's propensity to undergo arthroplasty via the posterior approach, and matched them to 1 control (anterolateral approach) based on age (±5 years), and propensity score. We used Chi-Square/Fisher-Exact tests to compare dichotomous outcomes, and repeated measures ANOVA to examine differences in patient-reported outcomes (via the WOMAC subscores) from baseline to one-year postoperative. We used logistic regression to identify independent predictors of reoperation for instability in the posterior group. We identified 1,306 patients for this sub-analysis, 876 (67.1%) who received arthroplasty via an anterolateral approach, and 430 (32.9%) a posterior approach. The unadjusted rate of reoperation was significantly higher in the posterior group (10.7% vs. 7.1%). Following propensity score matching, we retained 790 patients (395 per group), with no between-group differences in patient, fracture, or implant characteristics. The matched cohort had a higher rate of comorbidities, and were less likely to be employed vs. the unmatched cohort. The rate of treatment for dislocation remained higher in the posterior group (6.1% vs. 2.0%) following matching. Repeated measures ANOVA revealed significantly better WOMAC pain, stiffness, function, and total scores in the posterior group. Between-group differences at 12-months were: pain - 0.59 (0.03–1.15); stiffness - 0.62 (0.35–0.87); function - 2.99 (0.12–5.86); total - 3.90 (0.24–7.56). We identified THA (vs. HA, odds ratio 2.05 [1.05–4.01]) as the only independent predictor of treatment for dislocation in the posterior group. Our analyses revealed that compromised patients with displaced FNFs who undergo arthroplasty via the posterior approach may report better symptoms at one-year vs. the anterolateral approach, despite a higher odds of reoperation for instability

The SPAIRE technique (Saving Piriformis And Internus, Repair Externus) was first described in 2016 and an approach to the hip in the interval between the inferior gemellus and quadratus femoris can be used for both hemi- and total hip arthroplasty. The HemiSPAIRE technique in hip hemiarthroplasty for displaced intracapsular fractures has been compared with the standard lateral approach (advocated by NICE) in a pragmatic, superiority, multicentre, randomised controlled trial into postoperative mobility and function. This NIHR funded study was recruited between November 2019 and April 2022 and the results are reported in this presentation. The author has used the SPAIRE technique in 1026 routine primary total hip replacements since February 2016. The technique is described along with results from NJR data. SPAIRE is most challenging in patients with small anatomy, reduced offset, with an external rotation deformity. Particularly in these, but in all cases, MAKO robotic assistance facilitates accurate implantation of prostheses and precise recreation of biomechanics. The MAKO robot has been used in all cases since 2018 and SPAIRE/MAKO is now the standard of care in the author's practice. To evaluate whether robotic-assisted tendon-sparing posterior approaches (piriformis sparing and SPAIRE), improve patient outcomes in total hip arthroplasty compared with a robotic-assisted standard posterior approach, the NIHR Efficacy and Mechanism Evaluation Programme has recently funded the HIPSTER trial (HIP Surgical Techniques to Enhance Rehabilitation). This is a single-centre, double-blinded, parallel three-arm, randomised, controlled, superiority trial; recruitment is in progress. The greatest value of robotic assistance may be when it is used in combination with tendon-sparing surgery. Data is being gathered to evaluate whether the SPAIRE/MAKO technique confers benefits with regard the speed of post-op mobilisation as well as accelerated return to unrestricted function

Few surgical techniques to reconstruct the abductor mechanism of the hip have been reported, with outcomes reported only from case reports and small case series from the centres that described the techniques. As in many of our revision THA patients the gluteus maximus was affected by previous repeat posterior approaches, we opted to reconstruct the abductor mechanism using a vastus lateralis to gluteus medius transfer. We report the results of such reconstructions in seven patients, mean age 66 (range, 53–77), five females, presenting with severe abductor deficiency (MRC grade 1–2). Five patients had previous revision THA, two with a proximal femoral replacement, one patient had a primary THA after a failed malunited trochanteric fracture, and one patient had a native hip with idiopathic fatty infiltration of glutei of >90%. All patients had instrumented gait analysis, and surface electromyography (EMG) of the glutei, TFL, and vastus muscles simultaneously before surgery and at each post-op follow-up. Postoperatively, patients were allowed to weight bear as tolerated and were requested to wear an abduction brace for the first six weeks after surgery to protect the transfer. All patients improved after surgery and reached an abductor power of 3 or more. All patients walked without support six months after surgery and were satisfied with the result. Abductor function continued to improve beyond one year of follow-up, and some patients reached an abductor power of 5. EMG demonstrated that the transferred vastus lateralis started firing synchronously with gluteus medius after three months post-surgery, suggesting adaptation to its new function. No knee extension weakness was recorded. One patient complained of lateral thigh numbness and was dissatisfied with the cosmetic look of her thigh after surgery. Our preliminary results are encouraging and comparable with those achieved by the originators of the technique

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

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

A ceramic-on-ceramic hip resurfacing implant (cHRA) was developed and introduced in an MHRA-approved clinical investigation to provide a non metallic alternative hip resurfacing product. This study aimed to examine function and physical activity levels of patients with a cHRA implant using subjective and objective measures both before and 12 months following surgery in comparison with age and gender matched healthy controls. Eighty-two unilateral cHRA patients consented to this study as part of a larger prospective, non-randomised, clinical investigation. In addition to their patient reported outcome measures (PROMs), self- reported measures of physical activity levels and gait analysis were undertaken both pre- operatively (1.5 weeks) and post operatively (52 weeks). This data was then compared to data from a group of 43 age gender and BMI matched group of healthy controls. Kinetics and kinematics were recorded using an instrumented treadmill and 3D Motion Capture. Statistical parametric mapping was used for analysis. cHRA improved the median Harris Hip Score from 63 to 100, Oxford Hip score from 27 to 48 and the MET from 5.7 to 10.3. cHRA improved top walking speed (5.75km vs 7.27km/hr), achieved a more symmetrical ground reaction force profile, (Symmetry Index value: 10.6% vs 0.9%) and increased hip range of motion (ROM) (31.7° vs 45.9°). Postoperative data was not statistically distinguishable from the healthy controls in any domain. This gait study sought to document the function of a novel ceramic hip resurfacing, using those features of gait commonly used to describe the shortcomings of hip arthroplasty. These features were captured before and 12 months following surgery. Preoperatively the gait patterns were typical for OA patients, while at 1 year postoperatively, this selected group of patients had gait patterns that were hard to distinguish from healthy controls despite an extended posterior approach. Applications for regulatory approval have been submitted

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

The August 2024 Hip & Pelvis Roundup. 360. looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data

Aims

Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient’s functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA.

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To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

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The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

The significance of periprosthetic fractures about a total hip arthroplasty (THA) is becoming increasingly important. Recent studies have demonstrated post-operative periprosthetic fracture rates are higher amongst cemented polished taper slip (PTS) stem designs compared to collared cementless (CC) designs. However, in the National Joint Registry, the rate of intra-operative periprosthetic femoral fractures (IOPFF) with cementless implant systems remains higher (0.87% vs 0.42%. p <0.001) potentially leading to more post-operative complications. This study identifies the incidence of IOPFF, the fracture subtype and compares functional outcomes and revision rates of CC femoral implants with an IOPFF to CC stems and PTS stems without a fracture. 5376 consecutive CC stem THA, carried out through a posterior approach were reviewed for IOPFF. Each fracture was subdivided into calcar fracture, greater trochanter (GT) fracture or shaft fracture. 1:1:1 matched analysis was carried out to compare Oxford scores at one year. Matching criteria included; sex (exact), age (± 1 year), American Society of Anaesthesiologists (ASA) grade (exact), and date of surgery (± 6 months). Electronic records were used to review revision rates. Following review of the CC stems, 44 (0.8%) were identified as having an IOPFF. Of these 30 (0.6%) were calcar fractures, 11 (0.2%) GT fractures and 3 (0.06%) were shaft fractures. There were no shaft penetrations. Overall, no significant difference in Oxford scores at one year were observed when comparing the CC IOPFF, CC non-IOPFF and PTS groups. There were no CC stems revised for any reason with either a calcar fracture or trochanteric fracture within the period of 8 years follow-up. IOPFF do occur more frequently in cementless systems than cemented. The majority are calcar and GT fractures. These fractures, when identified and managed intra-operatively, do not have worse functional outcomes or revision rates compared to matched non-IOPFF cases

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The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

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Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear.

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Large bone defects resulting from osteolysis, fractures, osteomyelitis, or metastases pose significant challenges in acetabular reconstruction for total hip arthroplasty. This study aimed to evaluate the survival and radiological outcomes of an acetabular reconstruction technique in patients at high risk of reconstruction failure (i.e. periprosthetic joint infection (PJI), poor bone stock, immunosuppressed patients), referred to as Hip Reconstruction In Situ with Screws and Cement (HiRISC). This involves a polyethylene liner embedded in cement-filled bone defects reinforced with screws and/or plates for enhanced fixation.

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The aims of this study were to determine the success of a reconstruction algorithm used in major acetabular bone loss, and to further define the indications for custom-made implants in major acetabular bone loss.

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There are limited long-term studies reporting on outcomes of the Zimmer Modular Revision (ZMR) stem, and concerns remain regarding failure. Our primary aim was to determine long-term survival free from all-cause revision and stem-related failure for this modular revision stem in revision total hip arthroplasty (THA). Secondary aims included evaluating radiological and functional outcomes.