Background. Fifteen to twenty percent of patients presenting for total hip arthroplasty (THA) have bilateral disease. While simultaneous bilateral THA is of interest to patients and surgeons, debate persists regarding its merits. The majority of previous reports on simultaneous bilateral THA involve patients in the lateral decubitus position, which require repositioning, prepping and draping, and exposure of a fresh wound to pressure and manipulation for the contralateral THA. The purpose of this study was to compare complications, component position, and financial parameters for simultaneous versus staged bilateral THAs using the direct anterior approach (DAA). Methods. Medical records were reviewed for patient demographics, medical history, operative time, estimated blood loss (EBL), change in hemoglobin, transfusion, tranexamic acid (TXA) use, length of stay (LOS), discharge disposition, leg length discrepancy, acetabular cup position, and perioperative complications. Cost and reimbursement data were analyzed. Results. Forty-four patients were included in the sequential group and fifteen patients in the simultaneous group (Figure 1). Operative time was significantly longer for simultaneous DAA THA, with procedures lasting 260 +/− 48 minutes compared to 132 +/− 30 minutes for a single arthroplasty in the sequential group (p<0.001). Patients undergoing simultaneous bilateral DAA THA also had a significantly higher EBL (p<0.001), hemoglobin drop (p<0.001), and blood transfusion rate (p<0.01) compared to parameters for a single arthroplasty in the sequential group. This was despite TXA being used in a significantly higher proportion of simultaneous procedures compared to sequential procedures (p<0.01). The LOS was significantly longer in patients undergoing simultaneous bilateral DAA THA (2.9 +/− 1.0 days) compared to sequential (2.2 +/− 0.6 days) (p<0.001). No deep venous thrombosis (DVT) or pulmonary embolism (PE) was detected in either group during the observation period. No significant difference was detected regarding perioperative complications or whether patients were able to be discharged home instead of to a post-inpatient facility (Figure 2). There was no significant difference in component position, complications, or readmissions between groups. Total cost per hip was significantly less for the simultaneous ($15,565 +/− 1,470) compared to the sequential group ($19,602 +/− 3,094) (p<0.001). There was no significant difference in total payments between the simultaneous group ($25,717 +/− 4,404) and the sequential group ($24,926 +/− 8,203) (p=0.93). Thus, with lower cost and similar reimbursement, profit per hip was significantly higher for the simultaneous ($9,606 +/− 5,060) compared to the sequential group ($5,324 +/− 7,997) (p<0.05). (Figure 3). Conclusions. Significant data regarding simultaneous bilateral THA has been published but results are conflicting and different surgical approaches were used. To our knowledge only four previous reports have been published examining simultaneous bilateral THA performed via the DAA. While simultaneous DAA THA presents challenges, our results suggest that simultaneous DAA THA may add value to the healthcare system without resulting in increased complications compared to sequential hip arthroplasty

Aims. The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode. Patients and Methods. Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant. Results. Combined TJA was associated with increased risk of deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty, length of stay (LOS), and in-hospital costs compared with bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJA performed on separate days of the same admission showed no statistically significant differences when compared with same-day combined TJA, but trended towards decreased total costs and total complications despite increased LOS. Conclusion. Combined TJA is associated with increased in-hospital complications, LOS, and costs. We do not recommend performing combined TJA during the same hospital stay. Cite this article: Bone Joint J 2019;101-B:573–581

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

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

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

Background. One-stage bilateral total hip arthroplasty (THA) is twice as invasive as unilateral THA. Therefore, increases in bleeding, postoperative anemia, and complications are a concern. The purpose of this study was to investigate hemoglobin values and the use of autologous and allogenic blood transfusion after one-stage bilateral THA. Methods. Twenty-nine patients (7 men and 22 women; 58 hips) were treated with one-stage bilateral THA. The mean age of subjects at the time of surgery was 60.6 years. The average body mass index for patients was 21.7 kg/m. 2. The diagnoses were secondary osteoarthritis due to developmental dysplasia of the hip (n=25) and avascular necrosis (n=4). All patients had donated 800 ml of autologous blood in 2 stages preoperatively (1 to 4 weeks apart). All patients took iron supplements starting from 5 weeks preoperatively. For all patients, the procedure was performed under general anesthesia in the lateral decubitus position via a posterolateral approach. Intra-operative blood salvage was not used. Suction drains were inserted subfascially. As a general rule, pre-donated autologous blood was transfused back to the patients intra- or post-operatively. Allogenic blood transfusion was performed when clinical symptoms of anemia occurred (hypotension, low urinary output, tachycardia, etc.) rather than using a preset blood threshold (hemoglobin level <8 g/dl). To determine changes in blood pressure following surgery until the next morning, systolic and diastolic blood pressure were measured at 3-hr intervals. Results. The mean duration of surgery was 67.4 min for the procedure on the side that was operated on first, 32.7 min to change to the other side, and 68.4 min for the procedure on the other side. The mean blood loss was 576.1 ml. Hemoglobin values at baseline, at the time of autologous blood donation, and on the first day after surgery were 13.2, 12.7, and 8.7 g/dl respectively. Hemoglobin values were significantly different between the 2 weeks before surgery and the first day after surgery. Systolic and diastolic blood pressure were the lowest 3–6 hrs postoperatively (mean, 86/55). Blood reinfusion using autologous blood was performed for all patients. The allogenic blood transfusion rate was 25.0% (range, 2–8 units). In terms of complications, one patient developed an arrhythmia on postoperative day 5. This was the patient for whom autologous blood donation could not be performed due to pre-existing anemia. This patient also had right-sided sciatic nerve palsy. Discussion. With respect to one-stage bilateral THA, Gie showed that allogenic blood transfusion rate with or without autologous blood donation was 42% and 87% respectively. The allogenic blood transfusion rate was 25.0% in our study. Establishing a procedure to perform surgery in a shorter time period may further reduce the rate of allogenic blood transfusion. Although not used herein, intraoperative blood salvage may also be considered. Conclusions. In one-stage bilateral THA, autologous blood donation is effective in managing perioperative anemia and reducing the rate of allogenic blood transfusion. Perioperative blood management based on individual patients' situations are important for the safe performance of one-stage bilateral THA

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

Purpose. Bilateral simultaneous and staged total hip arthroplasty has been issues in terms of safety and costs with development of surgical technique, postoperative medical care. The purpose of this prospective study is to compare the outcomes of simultaneous and staged bilateral operations, in terms of outcome, safety, and socioeconomic-effectiveness. Patients and Methods. All patients(470 cases) that underwent simultaneous or staged bilateral THA using modified minimally invasive two-incision technique between January 2004 and November 2009 were registered, and after exclusion divided into two groups; simultaneous bilateral THA group (Group A: 171 patients) and staged bilateral THA group (Group B: 64 patients) by patient's condition and preference. Staged operations were performed at the time when patients want to get surgery due to undurable pain. For clinical evaluations, amounts of blood loss, blood transfusion, postoperative morbidity and mortality were compared. And for socioeconomic-effectiveness, costs for hospitalization and time for returning to previous job were investigated. Results. Overall complications were not significant between two groups and perioperative morbidity rates were similar in the two groups compared. (p=0.546). Patients in group A required more blood transfusions than those in group B (3.05 vs 1.93 unit, p=0.003), although blood losses in two groups were similar. (906 vs 936 cc, p=0.605) Average interval between staged operation in group B was 18.2 months (range, 2.2 ∼ 65.0 months). Average length of hospital stay was significantly shorter in group A (average 14.6 days) than in group B (average 24.2 days) (p<0.001). Group A showed 20% higher total medical cost than group B (9,240 US vs 11,107 US dollars) (p<0.05). Conclusions. There were no differences in clinical outcome, morbidity and mortality between simultaneous and staged bilateral THA. But simultaneous operation showed a cost-effectiveness with shorter hospitalization and early return to the previous job even though there still remained possibility of more blood transfusion

Background. Pre-operative autologous blood donation is recommended as a means of reducing the need for allogeneic transfusion before simultaneous bilateral total hip arthroplasty (THA). However, there have been few reports on the optimal amount of autologous donation for this procedure. In this study we sought to determine the amount of autologous blood required for patient undergoing simultaneous bilateral THA using the direct anterior approach. Methods. We retrospectively enrolled 325 consecutive patients (650 hips) underwent simultaneous bilateral primary THA from January 2012 to June 2014. Thirty-three patients were men and 290 patients were women. The patients’ mean age at THA was 59.1 years. All THAs were performed using the direct anterior approach. Intraoperative blood salvage was applied for all patients and postoperative blood salvage was not applied for any patients. Results. The mean intraoperative blood loss and the mean operative time for the bilateral procedure were 413±165 g and 87.2±12.3 minutes, respectively. Two hundreds and forty-one of the 325 patients (74.2%) donated an average of 1.9 (range, 1–2) units of autologous blood before the operation. The mean hemoglobin levels on the preoperative day, postoperative day 1 and postoperative day 5 were 12.5g/dl, 10.5 g/dl and 9.5 g/dl, respectively. Only 1 patient (0.3%) required postoperative transfusions of allogeneic blood. All of the autologous units collected were transfused, and no units were wasted. Conclusion. Simultaneous bilateral THA can be performed without allogenic blood transfusion in 99.7% of patients. We could not find out significant effectiveness of an average of 1.9 units of autologous blood donation for this procedure in this study. We concluded that simultaneous bilateral THA can be performed without autologous blood donation in healthy patients without severe hip deformity. Whereas, preoperative donation of autologous blood might be suitable for patients with low body weight or patients with severe hip deformity. The minimally invasive aspect of the direct anterior approach seems to allow a low rate of allogeneic blood transfusion in the study

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

Purpose. Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) is subjective assessment of coxarthropathy and reflects the satisfaction level of the patient. Recently, the use of JHEQ as a postoperative assessment of total hip arthroplasty (THA) has become widespread. The aim of this study was to investigate the clinical outcomes of bilateral simultaneous THA through the direct anterior approach (DAA) using JHEQ. Methods. This study included 34 patients (41 hips) who were treated with first THA at our hospital from January to March 2013 and were available for evaluation of clinical outcomes 1 year after surgery. Of these, 7 (2 males and 5 females; mean age, 54.7 years) underwent bilateral simultaneous THA (group B), and 27 (2 males and 25 females; mean age, 64.2 years) underwent unilateral THA (group U). Thirty patients were preoperatively diagnosed with hip osteoarthritis, and 4 were diagnosed with avascular necrosis of the femoral head. All patients were treated through DAA in a supine position under general anaesthesia. Items for evaluation included clinical outcomes, Japanese Orthopaedic Association Hip score (JOA score) and JHEQ. Results. Average operative time per hip was 45.9 min (range, 34–79 min) in group B and 44.2 min (range, 32–71 min) in group U. Average blood loss was 221.4 g (range, 40–1040 g) in group B and 386.9 g (range, 70–1300 g) in group U. No major complications such as dislocation, bone fracture, nerve palsy or venous thromboembolism were observed. The average JOA score improved from 45.1 preoperatively to 93.7 at 1 year postoperatively in group B and from 47.2 preoperatively to 92.3 at 1 year postoperatively in group U. Average total JHEQ (pain/motion/mental status) improved from 21 (preoperative, 12/2/7) to 75 (1 year postoperatively, 27/23/25) in group B and from 26 (preoperative, 10/7/10) to 69 (1 year postoperatively, 25/21/24) in group U. Discussion. Bilateral simultaneous THA was proactively performed when indicated at our hospital. In the present study, we observed greater improvement in JHEQ in patients treated with bilateral simultaneous THA than in those treated with unilateral THA. These findings suggest that bilateral simultaneous THA results in greater postoperative satisfaction of the patient

Although the impact of sexual difficulties on quality of life in patients with hip osteoarthritis has been documented in previous literature, recent research has shown that surgeons rarely discuss this sensitive topic with patients. The purpose of this study was to develop an educational tool to address common questions that patients may have regarding returning to sexual activity following their total hip arthroplasty (THA). The study was conducted in two phases. In Phase 1, patients who underwent a THA between 2013–2017 at a single centre were retrospectively identified and sent an anonymous online survey. This survey was aimed at assessing patient-specific concerns regarding whether they would have liked to receive information about returning to sexual activity, what information they would have liked to know and how they would have liked to receive this information. An educational tool was developed based on the findings of Phase 1. In Phase 2, prospective patients who were scheduled for a unilateral or bilateral THA were provided with the educational tool prior to their surgery. A questionnaire was administered to evaluate the effectiveness of this educational tool. Descriptive statistics and chi-squared tests were used for data analysis. In Phase 1, the overall response rate was 34.7% (n = 58/167). Out of the total respondents, 51.7% indicated an interest in receiving information on when to return to sexual activity following a THA. Patients selected an informational pamphlet as the most desired method of receiving information (p = .044). In Phase 2, the response rate was 54.5% (n = 30/55). Overall, 90% of patients felt that the pamphlet addressed all their concerns, and 93.3% felt they were provided with adequate information on how they could get more information. The pamphlet addressed questions regarding when it was safe to resume sexual activity following a THA, what positions were safe, and the associated risks. Individuals undergoing a THA are modestly interested in receiving information regarding when to return to sexual activity following their surgery, especially those who are sexually active preoperatively. This educational pamphlet may be useful in routine clinical practice in addressing concerns regarding returning to sexual activity. Understanding patients' goals and expectations for their postoperative course may help surgeons provide a more comprehensive approach to patient care

The direct anterior (DA) approach for total hip arthroplasty (THA) has become increasingly popular in North America. With experience, exposure of both the acetabulum and femur can be achieved similar to those in other approaches. In cases of difficult femoral exposure, the conjoint tendon of the short external rotators can be released to improve visualisation. The effect of conjoint tendon release has not been previously explored in regards to overall outcomes, or postoperative pain. The goal of this study was to evaluate 1) the length of stay and inpatient pain medication requirements of patients undergoing DA THA on the basis of conjoint tendon release, and 2) whether conjoint tendon release influenced functional outcomes. We conducted a retrospective chart review of all cases of primary DA THAs conducted by single surgeon at LHSC University between August 2012 and July 2015. Patient demographics, bilateral THA cases, intraoperative conjoint tendon or other soft tissue releases, intra-operative complications, and length of stay (LOS) were evaluated for all cases. Inpatient pain medication data was available for all cases from Apr 2014 onwards. One year functional outcome scores, including WOMAC and Harris Hip Scores (HHS), were evaluated for all cases before August 2014. Six-week and three-month functional outcome scores were available and evaluated for a subset of cases. All data was analysed with multiple linear regression. Three hundred and twelve cases of primary DA THAs were identified, of which 29 were concurrent bilateral THAs. One hundred and eighty cases included a conjoint tendon release, while 29 cases had other soft tissue releases (tensor fascia lata). Mean age and BMI were 64.9±11.5 years and 29.0±5.3 respectively. Mean LOS was 1.3±1.1 days, with age, bilateral THA, non-conjoint tendon soft tissue release, and intra-operative complications being predictive of LOS (p<0.05). Pain medication data was available for 107 cases, of which 11 were concurrent bilateral THAs. Sixty four cases included a conjoint tendon release, while one case had other soft tissue releases. Mean daily morphine equivalent dose (MED) narcotic use was 43.2±48.2mg, with age being a negative predictor of narcotic use (p<0.05). BMI was a negative predictor of one year HHS pain, HHS total, and all WOMAC subcategory scores, while age was a negative predictor of one year HHS function and HHS total scores (p<0.05). None of the variables were predictive of six-week and three-month functional outcome scores. Conjoint tendon release was not predictive of LOS, inpatient pain medication requirements, or outcome scores. Conjoint tendon release did not affect postoperative pain, LOS, or functional outcomes. Given that conjoint release improves femoral exposure, intraoperative thresholds for conjoint release should be low. The effect of intraoperative release of other soft tissues is uncertain, as this increased LOS but not postoperative pain

Iliopsoas tendonitis after total hip arthroplasty (THA) can be a considerable cause of pain and patient dissatisfaction. The optimal cup position to avoid iliopsoas tendonitis has not been clearly established. Implant designs have also been developed with an anterior recess to avoid iliopsoas impingement. The purpose of this cadaveric study was to determine the effect of cup position and implant design on iliopsoas impingement. Bilateral THA was performed on three fresh frozen cadavers using oversized (jumbo) offset head center revision acetabular cups with an anterior recess (60, 62 and 66 mm diameter) and tapered wedge primary stems through a posterior approach. A 2mm diameter flexible stainless steel cable was inserted into the psoas tendon sheath between the muscle and the surrounding membrane to identify the location of the psoas muscle radiographically. CT scans of each cadaver were imported in an imaging software. The acetabular shells, cables as well as pelvis were segmented to create separate solid models of each. The offset head center shell was virtually replaced with an equivalent diameter hemispherical shell by overlaying the outer shell surfaces of both designs and keeping the faces of shells parallel. The shortest distance between each shell and cable was measured. To determine the influence of cup inclination and anteversion on psoas impingement, we virtually varied the inclination (30°/40°/50°) and anteversion (10°/20°/30°) angles for both shell designs. The CT analysis revealed that the original orientation (inclination/anteversion) of the shells implanted in 3 cadavers were as follows: Left1: 44.7°/23.3°, Right1: 41.7°/33.8°, Left2: 40/17, Right2: 31.7/23.5, Left3: 33/2908, Right3: 46.7/6.3. For the offset center shells, the shell to cable distance in all the above cases were positive indicating that there was clearance between the shells and psoas. For the hemispherical shells, in 3 out of 6 cases, the distance was negative indicating impingement of psoas. With the virtual implantation of both shell designs at orientations 40°/10°, 40°/20°, 40°/30° we found that greater anteversion helped decrease psoas impingement in both shell designs. When we analyzed the influence of inclination angle on psoas impingement by comparing wire distances for three orientations (30°/20°, 40°/20°, 50°/20°), we found that the effect was less pronounced. Further analysis comparing the offset head center shell to the conventional hemispherical shell revealed that the offset design was favored (greater clearance between the shell and the wire) in 17 out of 18 cases when the effect of anteversion was considered and in 15 out of 18 cases when the effect of inclinations was considered. Our results indicate that psoas impingement is related to both cup position and implant geometry. For an oversized jumbo cup, psoas impingement is reduced by greater anteversion while cup inclination has little effect. An offset head center cup with an anterior recess was effective in reducing psoas impingement in comparison to a conventional hemispherical geometry. In conclusion, adequate anteversion is important to avoid psoas impingement with jumbo acetabular shells and an implant with an anterior recess may further mitigate the risk of psoas impingement

Corrosion in modular taper connections of total joint replacement has become a hot topic in the orthopaedic community and failures of modular systems have been reported. The objective of the present study was to determine in vivo titanium ion levels following cementless total hip arthroplasty (THA) using a modular neck system. A consecutive series of 173 patients who underwent cementless modular neck THA and a ceramic on polyethylene bearing was evaluated retrospectively. According to a standardized protocol, titanium ion measurements were performed on 67 patients using high-resolution inductively coupled plasma-mass spectrometry. Ion levels were compared to a control group comprising patients with non-modular titanium implants and to individuals without implants. Although there was a higher range, modular-neck THA (unilateral THA: 3.0 μg/L (0.8–21.0); bilateral THA: 6.0 μg/L (2.0–20.0)) did not result in significant elevated titanium ion levels compared to non-modular THA (unilateral THA: 2.7 μg/L (1.1–7.0), p = 0.821; bilateral THA: 6.2 μg/L, (2.3–8.0), p = 0.638). In the modular-neck THA group, patients with bilateral implants had significantly higher titanium ion levels than patients with an unilateral implant (p < 0.001). Compared to healthy controls (0.9 μg/L (0.1–4.5)), both modular THA (unilateral: p = 0.029; bilateral p = 0.003) and non-modular THA (unilateral: p < 0.001; bilateral: p < 0.001) showed elevated titanium ion levels. The data suggest that the present modular stem system does not result in elevated systemic titanium ion levels in the medium term when compared to non-modular stems. However, more outliner were seen in modular-neck THA. Further longitudinal studies are needed to evaluate the use of systemic titanium ion levels as an objective diagnostic tool to identify THA failure and to monitor patients following revision surgery

Introduction. There have been significant advancements in postoperative care following total hip arthroplasty (THA) over the past decade and it is essential to quantify the impact of efforts made to better optimize patients and improve postoperative care. The purpose of this study was to assess trends in discharge destination, length of stay (LOS), and readmissions following primary THA. Methods. Patients undergoing primary THA during 2011–2017 were identified in the American College of Surgeons National Quality Improvement Program using CPT code 27130. Non-elective surgery and simultaneous bilateral THA procedures were excluded. Patients were classified as having discharged home or to not home locations. Trends in discharge destination, LOS, 30-day readmission, 30-day reoperation, and American Society of Anesthesiologists (ASA) classification were assessed using the Cochran-Armitage test. Results. Of the 155,638 primary THA patients analyzed, 81% discharged home and 19% did not discharge home. From 2011–2017 there was a 21% increase in percentage of patients discharging home (72% in 2011, 87% in 2017, p<0.001) despite a significantly increasing number of patients with ASA score ≥ 3 (34% to 40%, p<0.001, Figure 1). Over this time period, hospital LOS decreased from 3.1 to 2.0 days for those discharging home (p<0.001) and from 3.8 to 3.6 days those not discharging home (p=0.003). There were no significant changes in 30-day reoperation rates for patients discharging home and readmission rates significantly decreased over time (3.2% in 2011 to 2.6% in 2017, p=0.02). Conclusion. From 2011–2017, patients undergoing THA were more likely to discharge home, had shorter hospital LOS and significantly decreased readmission rates. These trends persisted despite an increasingly comorbid patient population. It is likely these trends have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements should be considered when changes to reimbursement are being evaluated. For any tables or figures, please contact the authors directly

Background. Method of fixation in THA is a contentious issue, with proponents of either technique citing improved implant survival and outcomes. Current comparisons rely on insufficiently powered studies with short-term follow up or larger poorly controlled registry studies. Patient factors are considered a key variable contributing to the risk of implant failure. One way to overcome this confounder is to compare the survival of cementless and cemented THAs patients who have undergone bilateral THAs with cemented hip on one side and cementless hip on the other. We compared stem survival of patients who have bilateral THA with one cemented stem in one hip and a cementless stem in the contralateral hip in the National Joint Registry. Methods. UK National Joint Registry is the largest registry of its kind in the world. This study included 2934 patients with 5868 THAs who underwent bilateral THAs s between 2003 and 2016. These patients had undergone bilateral sequential THAs within 3 years of each other: cemented THA on one side and cementless on the other, Patients had identical pre-operative American Society of Anaesthesiologists group for both THAs and same indication for surgery. Implant survival was compared using Cox regression with an endpoint of stem revision. Results. Ten-year all-cause survival of cementless stems was lower than for cemented stems (p<0.001), as was survival to aseptic loosening revision (p<0.001). Similar trends were seen across all age groups including young and old patients. There was a non-significant trend towards superiority of cemented stems in survival until periprosthetic fracture, dislocation and infection. Conclusion. Comparison of cementless with cemented stems within patients is a novel method to compare the outcomes of orthopaedic implants. Survival was better for cemented stems including for younger patients and aseptic loosening

Introduction. Higher concentrations of metal ion levels after Metal-on-metal (MoM) THA are a cause for concern. Elevated cobalt (Co) and chromium (Cr) ion levels in the blood indicate metal wear, and may predict secondary soft-tissue damage (adverse reaction to metal debris; ARMD). Although, it is well known that concentrations of metal ion levels are elevated in the short term after MoM, the long-term consequences in ion concentration and risk factors for increased ion levels are not clarified. We sequentially investigated the postoperative Co and Cr ion levels after MoM THA and the relationship between the metal ion levels and several risk factors. Materials and Methods. We reviewed the data on one hundred and eighty six patients of two hundred ninety one MoM THA cases. The one hundred eighty six patients were measured at least three times after a MoM THA surgery over a five year (2005–2010) period in our institution. Serum cobalt and chromium levels were measured by inductor coupled plasma – mass spectrometry at several times in follow-up period, (measured at the preoperative period, the third month, the sixth month, the first year, the second year, and the fourth year after MoM THA). Furthermore, we investigated the correlation between the metal ion levels and various factors which might influence the release of metal ions, such as Body mass index (BMI), renal function, femoral head size, unilateral or bilateral THA, the cup position, and postoperative activity. The renal function was evaluated by measuring estimated glomerular filtration ratio (GFR) at preoperative examination. A postoperative activity was assessed with a pedometer measurement counting number of steps a day. A cup position was evaluated by lateral inclination measured by X-ray or computed tomography. Results. Average serum Co and Cr concentrations in preoperative period were 0.69 and 0.05 mg/ ml, respectively. Postoperative serum Co and Cr ion levels were significantly increased compared with preoperative value throughout the postoperative period. There was no significant correlation with regards to BMI, renal function, femoral head size tothe metal ion level measurement. In bilateral THA cases, Co and Cr ion concentrations were significantly increased compared with unilateral THA cases. In addition, in cases that its cup inclination was more than 50 degrees, Co and Cr ion concentration were significantly increased compared with cases less than 50 degrees in the first year after surgery. There was a trend for higher metal ion levels in the group of patients who walked more than 7000 steps a day, but this did not reach statistical significance. Conclusion. Metal ion concentrations of almost patients were increased after MoM THA surgery. Side effects related to elevation of serum Co or Cr concentration were currently not identified and overall clinical results were good. However, Longer follow-up would be necessary if the patients have overlapping risk factors, because those patients may experience elevation of the level in postoperative late stage

We compared the long-term clinical outcome scores of the Stanmore total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA, n=26 subjects) versus osteoarthritis (OA, n=35 subjects) at a mean of 12 years after THA. Patients with RA were a mean of 11 years younger at review (66 years, P< 0.001) than those with OA. A greater proportion of RA patients had bilateral THA (19/26 versus 12/35, p=0.03), and were of Charnley grade C (23/26 versus 2/35, p< 0.001). The proportion of male versus female subjects and body mass index were similar between groups (p> 0.05 all comparisons). The overall SF-12 score and SF-12 physical component score were 8% and 15% poorer, respectively, in subjects with RA versus those with OA (P< 0.05). The hip-specific Oxford and Harris hip scores, however, were similar between groups (p> 0.05). Within the individual domains of the Harris hip score, patients with RA had poorer scores for walking distance, stair climbing, putting on of socks/shoes, and ability to enter public transport (p< 0.05 all comparisons). The other domains of pain, limp, use of walking aids, sitting, deformity and range of movement were similar between groups (p> 0.05). The observed differences in outcome scores between RA and OA groups were independent of age and whether the patient had bilateral THA (ANOVA, p> 0.05). Clinical outcome scores in the long term after THA are poorer in RA subjects versus OA. The principal differences occur in the ability to walk long distances, and the use of stairs and public transport