Although day surgery has a good patient satisfaction and safety profile, accurate episode-of-care costs (EOCC) calculation for of this procedure compared to standard same-day admission (SDA), while considering functional outcomes, is not well known. This study assesses the EOCC for patients with a THA while comparing DS and Same Day Admission (SDA) (with a 1-day hospitalization) pathways. The episode-of-care cost (EOCC) of 50 consecutive day surgery and SDA patients who underwent a THA was evaluated. The episode-of-care cost was determined using a bottom-up Time Driven- Activity Based Funding method. Functional outcomes were measured using preoperative and postoperative Harris Hip Score (HHS). Overall, the SDA THA cost 11% more than a DS THA. The mean total EOCC of DS THA was 9 672 CAD compared to 10 911 CAD in the SDA THA group. Both groups showed an improvement in HHS score following the procedure but patients in the DS group had a significantly higher postoperative HHS score and a significantly greater improvement in their HHS score postoperatively. Day surgery THA is cost-effective, safe and associated with high patient satisfaction due to functional improvement. Providing policymakers the information to develop optimal financing methods is paramount for clinicians wishing to develop modern protocols, increase productivity while providing the optimal care for patients

Abstract. Background. Conventional periacetabular pelvic resections are associated with poor functional outcomes. Resections through surgical corridors beyond the conventional margins may be helpful in retaining greater function without compromising the oncological margins. Methods. The study included a retrospective review of 82 cases of pelvic resections for pelvic tumors. Outcomes of acetabulum preservation (Group A) were compared with complete acetabular resection (Group B). Also, we compared outcomes of Type I+half resections (Group 1) with Type I+II resections (Group 2), and Type III+half resections (Group 3) with Type II+III resections (Group 4). Results. Group A (n=44) had significantly better functional outcome than Group B(n=38) with average MSTS93 score 22.3 vs 20.1 and average HHS 91.3 vs 82.5 (p<0.001). Group 1(n=14) and Group 2(n=12) had similar functional outcomes (mean MSTS93 score 22.07 vs 21.58 (p=0.597) and mean HHS 90.37 vs 86.51 (p=0.205)). Group 3(n=11) had significantly better functional outcome than Group 4(n=17), with mean MSTS93 score 22.8 vs 19.7 (p<0.001) and mean HHS 92.3 vs 80.1 (p<0.001). Oncological outcomes were similar among the groups. Conclusion. Trans-acetabular pelvic resections provide functional benefit over conventional resections without compromising oncological margins. There is a need to revisit and revise the pelvic resection planes

Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Introduction. Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome. Materials & Methods. A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone. Results. 1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value <0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value <0.0001). Conclusions. Although good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR. A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year VAS pain. PCS-magnification CRC sub-domain was also identified as a significant predictor of KSS/HHS at one-year (median difference 1.3, 95% CI −5.23–0.11, p=0.041). Preoperative VAS pain, Oxford and HHS/KSS scores were significantly inferior in patients who had CRC PCS, abnormal HADS-A, and abnormal HADS-D scores compared to patients with normal scores. At one-year, PCS CRC patients also had significantly inferior VAS pain (p=0.001), Oxford (p < 0 .0001) and KSS/HHS (p=0.025). Abnormal HADS-A and HADS-D patients experienced significantly inferior postoperative VAS pain (HADS-A p=0.025, HADS-D p=0.030), Oxford (HADS-A p=0.001, HADS-D p=0.030), but no difference in KSS/HHS (HADS-A = 0.069, HADS-D = 0.071) compared to patients with normal PCS/HADS scores. However, patients with CRC PCS experienced significantly greater improvement in preoperative to postoperative VAS pain (p < 0 .0001), Oxford (p=0.003) and HHS/KSS (p < 0 .0001). Similarly, patients with abnormal HADS scores showed significant improvement in preoperative to one-year postoperative change scores, as compared to normal patients in VAS pain (HADS-A p=0.011, HADS-D p=0.024), KSS/HHS (HADS-A p=0.017, HADS-D p=0.031), but not Oxford (HADS-A p=0.299, HADS-D p=0.558). Patients who are anxious, depressed or who pain catastrophize have worse preoperative function and pain. Postoperatively, pain and functional outcomes are also inferior in such patients, however they do experience a significantly greater improvement in outcomes. Furthermore, it appears that rumination and anxiety traits predict pain levels postoperatively. Although these patients report higher levels of pain postoperatively, as compared to preoperative, great improvement can be expected following hip and knee TJR

The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure. We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 5.1yrs from 2.9 to 9.4 years). The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 5.1 yrs) when compared to preoperative scores. These results suggest that bikini incision DAA technique can be safely utilised to perform THA

Post-traumatic osteonecrosis of the femoral head (ONFH) is a major complication of femoral neck fractures that require numerous solutions. The purpose of the current study is to investigate the effects of platelet-rich plasma (PRP) incorporated autologous granular bones graft for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH. A total of 46 patients were eligible and enrolled into the study. 24 patients were treated with core decompression and PRP incorporated autologous granular bones graft (treatment group: 9 females and 15 males, age range, 16–39 years), and 22 patients with core decompression and autologous granular bones graft (control group: 6 females and 16 males, age range, 18–42 years. During a minimum duration of follow-up of 36 months, multiple imaging techniques including X-ray and computed tomography (CT) scanning were used to evaluate the radiological results, and Harris hip score (HHS) and the visual analogue scale (VAS) were chosen to assess the clinical results. Both treatment group and control group had a significant improved HHS (P < 0.001). The minimum clinically important difference (MCID) for HHS was reached in 91.7% of treatment group and 68.2% of control group (P = 0.0449). HHS in treatment group was significantly higher than control group at the last follow-up (P = 0.0254). VAS score was significantly declined in treatment group when compared with control group (P = 0.0125). Successful clinical results were achieved in 21 of 24 patients (87.5%) in treatment group compared with 13 of 22 patients (59.1%) in control group (P = 0.0284). Successful radiological results were achieved in 19 of 24 patients (79.2%) in treatment group compared with 11 of 22 patients (50%) in control group (P = 0.0380). The survival rates using requirement for further hip surgery as an endpoint were higher in treatment group in comparison to control group (P = 0.0260). The PRP incorporated autologous granular bones graft is a safe and effective procedure for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH

Background. Postoperative dislocation is one of the main surgical complications and the primary cause for revision surgery after 2-stage implant exchange due to periprosthetic infection of a total hip arthroplasty. Objective. The aims of our study were (1) to determine the incidence of dislocation after two-stage THA reimplantation without spacer placement, (2) to evaluate relevant risk factors for dislocation and (3) to assess the final functional outcome of those patients. Method. We prospectively analyzed 187 patients who underwent a two-stage total hip arthroplasty (THA) revision after being diagnosed with periprosthetic joint infection (PJI) from 2013 to 2019. The mean duration of follow-up was 54.2 ± 24.9 months (>36 months). The incidence of postoperative dislocation and subsequent revision was estimated through Kaplan-Meier curves and potential risk factors were identified using Cox hazard regression. The functional outcome of the patients was assessed using the modified Harris Hip Score (mHHS). Results. The estimated cumulative dislocation-free survival was 87.2% (95% CI: 81.2%-91.3%) with an estimated 10% and 12% risk for dislocation within the first 6 and 12 months, respectively. The use of a dual-mobility construct had no significant impact on the dislocation rate. Increasing body mass index (BMI) (HR=1.11, 95% CI: 1.02-1.19, p=0.011), abductor mechanism impairment (HR=2.85, 95% CI: 1.01-8.01, p=0.047), the extent of elongation of the affected extremity between stages (HR=1.04, 95% CI: 1.01-1.07, p=0.017), the final leg length discrepancy (HR=1.04, 95% CI: 1.01-1.08, p=0.018) and PJI recurrence (HR=2.76, 95% CI: 1.00-7.62, p=0.049) were found to be significant risk factors for dislocation. Overall revision rates were 17% after THA reimplantation. Dislocated hips were 62% more likely to undergo re-revision surgery (p<0.001, Log-rank= 78.05). A significant average increase of 30 points in mHHS scores after second-stage reimplantation (p=0.001, Wilcoxon-rank) was recorded, but no difference was noted in the final HHS measurements between stable and dislocated hips. Conclusion. Dislocation rates after 2-stage THA reimplantation for PJI remain high, especially regarding overweight or re-infected patients. Careful leg length restoration and an intact abductor mechanism seem critical to ensure stability in these complex patients

Aim. Aim of this monocentric, prospective study was to evaluate the safety, efficacy, clinical and radiographical results at 24-month follow-up (N = 6 patients) undergoing hip revision surgery with severe acetabular bone defects (Paprosky 2C-3A-3B) using a combination of a novel phase-pure betatricalciumphosphate - collagen 3D matrix with allograft bone chips. Method. Prospective follow-up of 6 consecutive patients, who underwent revision surgery of the acetabular component in presence of massive bone defects between April 2018 and July 2019. Indications for revision included mechanical loosening in 4 cases and history of hip infection in 2 cases. Acetabular deficiencies were evaluated radiographically and CT and classified according to the Paprosky classification. Initial diagnosis of the patients included osteoarthritis (N = 4), a traumatic fracture and a congenital hip dislocation. 5 patients underwent first revision surgery, 1 patient underwent a second revision surgery. Results. All patients were followed-up radiographically with a mean of 25,8 months. No complications were observed direct postoperatively. HHS improved significantly from 23.9 preoperatively to 81.5 at the last follow-up. 5 patients achieved a defined good result, and one patient achieved a fair result. No periprosthetic joint infection, no dislocations, no deep vein thrombosis, no vessel damage, and no complaint about limbs length discrepancy could be observed. Postoperative dysmetria was found to be + 0.2cm (0cm/+1.0cm) compared to the preoperative dysmetria of − 2.4 cm (+0.3cm/−5.7cm). Conclusions. Although used in severe acetabular bone defects, the novel phase-pure betatricalciumphosphate - collagen 3D matrixshowed complete resorption and replacement by newly formed bone, leading to a full implant integration at 24 months follow-up and thus represents a promising method with excellent bone regeneration capacities for complex cases, where synthetic bone grafting material is used in addition to autografts

INTRODUCTION. Short femoral stem use in total hip arthroplasty (THA) has increased due to positive short-term clinical and biomechanical success. A neck preserving femoral stem not only preserves proximal bone volume, but preserves the high quality bone of the medial neck. The short stem design allows for less invasive surgical exposure and less invasive violation of the femoral canal (Figure 1). Additionally, it facilitates future revision THA, if needed, with a conventional primary stem. The objective of this study was to evaluate the early clinical outcomes of the Alteon® Neck Preserving Femoral Stem (Exactech, Inc.). METHODS. Forty-nine subjects (25 males, 24 females; mean age: 58.3±7.6 years; mean BMI: 29.8±5.6) from 2 sites underwent primary THA with the Alteon Neck Preserving Femoral Stem. All participants signed the informed consent, and both sites received IRB approval prior to conducting the study. Clinical data outcomes for this study included the Harris Hip Score (HHS), the Oxford Hip Score (OHS), revisions, and subsidence at 3-month, 1-year, and 2-year post-operative time points. Subsidence was measured by an independent third party. Student t-tests were used to identify significant mean differences between genders (p<0.05). RESULTS. The means and standard deviations for the HHS and OHS are shown in Figures 2 and 3 respectively. For patients reaching the 2-year post-operative time point (n=28), the HHS improved by 51.3 points to 96.1 from 44.8 and the OHS improved by 23.0 points to 43.8 from 20.8. There was no significant difference between genders with regard to BMI or post-operative HHS or OHS scores. However, the females were significantly older (61.4 vs. 55.3) and had a significantly lower pre-operative HHS (44.3 vs. 53.5). There were 2 revisions reported, and there was one report of subsidence at 1 year (n=33); zero reports of subsidence at 2 years (n=24). DISCUSSION. The neck preserving femoral stem exhibited positive early clinical results as demonstrated by the marked improvement in functional outcome scores from the pre-operative visit to 2-years post-operative. These 2-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Functional outcomes scores kept improving at the 3-month, 1-year, and 2-year post-operative visits. Additional 2-year outcomes data will be incorporated into this dataset as they become available. For the two revisions, one was due to a calcar fracture and one was due to a patient fall. The patient who fell reported weight-bearing pain after the fall at the 1-year post-operative visit and was subsequently revised. Stem movement was documented as a result of the fall; this was the only report of subsidence. SIGNIFICANCE. The neck preserving femoral stem evaluated in this study demonstrated positive early clinical performance with no reports of subsidence (except for one case that was revised due to a fall). This neck preserving stem design is a promising alternative to conventional femoral stems. For any figures or tables, please contact authors directly

INTRODUCTION. Additive manufacturing (3D printing) is used to create porous surfaces that promote bone ingrowth in an effort to improve initial stability and optimize long-term biological fixation. The acetabular cup that was studied is manufactured with titanium alloy powder via electron beam melting. Electron beam melting integrates the porous and solid substrate rather than sintering a porous coating to a solid surface. The 3D-printed acetabular cup's high surface coefficient of friction (up to 1.2), combined with its geometry, creates a predictable press-fit in the acetabulum, improving initial mechanical stability and ultimately leading to reproducible biologic fixation. The objective of this study was to evaluate the early clinical outcomes and implant fixation of this 3D-printed acetabular cup in total hip arthroplasty (THA). METHODS. Four hundred twenty-eight subjects from 8 US and international research sites underwent primary THA with the 3D-printed acetabular cup. All sites received IRB approval prior to conducting the study, and all participants signed the informed consent. Screw usage and number used during surgery were used as a surrogate measurement for initial implant fixation. Clinical performance outcomes included pre- and post-operative Harris Hip Scores (HHS) and Oxford Hip Scores (OHS), patient satisfaction, and revision assessment. 215 patients had a minimum 1-year post-operative follow-up visit. Student t-tests were used to identify significant mean differences (p<0.05). RESULTS. Acetabular screws were used in 206 of 428 cases (48.1%); 85.9% used 1 screw, 12.6% used 2 screws, and 1.5% used 3 screws. For patients with a 1-year post-operative visit, the HHS improved by 49.8 points to 91.9 from 42.1, and the OHS improved by 27.7 points to 44.4 from16.7. Patient satisfaction scores at the 1-year post-operative visit were 9.7±0.7 (n=94). There was no significant difference between genders with regard to BMI, the 1-year post-operative HHS, OHS, or patient satisfaction scores. However, the males were significantly younger (59.8 vs. 62.9 years) and had significantly higher pre-operative HHS (45.7 vs. 37.9) and OHS scores (17.8 vs. 15.3). There were 9 revisions reported. DISCUSSION. For initial implant fixation, compared to a similar, non-3D-printed acetabular cup in the same product line, the 3D-printed cup used significantly fewer screws per case (n=1 for 85.9% cases vs. n=2 for 85.7% of cases) in a fewer percentage of cases (48.1% vs. 70.4%), suggesting greater initial stability and “scratch fit”. The 3D-printed acetabular cup also displayed positive early clinical results as evidenced by the pronounced improvement in clinical outcome scores from the pre-operative visit to the 1-year post-operative visit. These 1-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Patient satisfaction scores were also excellent (9.7/10). There were nine revisions; however, four of these were due to patient falls and one was due to infection. SIGNIFICANCE. The 3D-printed acetabular cup evaluated in this study demonstrated improved implant fixation and positive early clinical outcomes for THA

Aims. The incidence of thigh pain with the short stem varies widely across different studies. We aimed to evaluate the incidence and characteristics of post-operative thigh pain after using a particular bladed short stem and its potential risk factors. Patients and Methods. We respectively reviewed 199 consecutive patients who underwent unilateral total hip replacement using the Tri-lock stem from 2013–2016, of which 168 patients were successfully followed up with minimum two year clinical follow-up. All information about thigh pain and pre- and postoperative HHS score were gathered and all preoperative and immediate postoperative radiographs were available for review. Any complications were recorded. Results. Of the 168 patients, 34 (20.2%) patients reported thigh pain at a mean 3.1 years after surgery. Of these, 2 (5.9%) reported severe pain (NRS 5 or more). The pain was persistent (from surgery to final follow-up) in 13 patients (38.2%) and subsided within 2 years in 10 cases (29.4%). The most common site of pain was the lateral thigh (70.6%). The HHS improved from a mean 54.2 points preoperatively to 79.8 postoperatively. In 123 cases with radiographs at more than 2 years follow-up, all femoral stems were well-fixed and no revision surgery was needed at the latest. BMI and CFI were found to be independent risk factors for thigh pain after using this particular stem component. Conclusions. The incidence of thigh pain in Chinese THA patients with a bladed short stem component design is as high as 20%. Among them, nearly 40% will have some disruption in sleep or daily life. More than one-third of the cases of thigh pain were persistent. A larger BMI and patients with a funnel-type morphology of the femoral canal are independent risk factors for thigh pain in the setting of this particular stem component

While Oxidized Zirconium (OxZr) femoral heads matched with highly cross-linked polyethylene (XLPE) have demonstrated the lowest rate of revision compared to other bearing couples in the Australian National Joint Registry, it has been postulated that these results may, in part, be due to the fact that a single company offers this bearing option with a limited combination of femoral and acetabular prostheses. The purpose of this study was to assess clinical and radiographic outcomes in a matched cohort of total hip replacements (THR) utilizing an identical cementless femoral stem and acetabular component with either an Oxidized Zirconium (OxZr) or Cobalt-Chrome (CoCr) femoral heads at a minimum of 10 years follow-up. We reviewed our institutional database to identify all patients whom underwent a THR with a single cementless femoral stem, acetabular component, XLPE liner and OxZr femoral head with a minimum of 10 years of follow-up. These were then matched to patients who underwent a THR with identical prosthesis combinations with CoCr femoral head by gender, age and BMI. All patients were prospectively evaluated with WOMAC, SF-12 and Harris Hip Score (HHS) preoperatively and postoperatively at 6 weeks, 3 months, 1 and 2 years and every 2 years thereafter. Charts and radiographs were reviewed to determine the revision rates and survivorship (both all cause and aseptic) at 10 years for both cohorts. Paired analysis was performed to determine if differences exist in patient reported outcomes. There were 208 OxZr THRs identified which were matched with 208 CoCr THRs. There was no difference in average age (OxZr, 54.58 years, CoCr, 54.75 years), gender (OxZr 47.6% female, CoCr 47.6% female), and average body max index (OxZr, 31.36 kg/m2, CoCr, 31.12 kg/m2) between the two cohorts. There were no significant differences preoperatively in any of the outcome scores between the two groups (WOMAC (p=0.449), SF-12 (p=0.379), HHS(p=0.3718)). Both the SF12 (p=0.446) and the WOMAC (p=0.278) were similar between the two groups, however the OxZr THR cohort had slightly better HHS compared to the CoCr THR cohort (92.6 vs. 89.7, p=0.039). With revision for any reason as the end point, there was no significant difference in 10 years survivorship between groups (OxZr 98.5%, CoCr 96.6%, p=0.08). Similarly, aseptic revisions demonstrated comparable survivorship rates at 10 year between the OxZr (99.5%) and CoCr groups (97.6%)(p=0.15). Both THR cohorts demonstrated outstanding survivorship and improvement in patient reported outcomes. The only difference was a slightly better HHS score for the OxZr cohort which may represent selection bias, where OxZr implants were perhaps implanted in more active patients. Implant survivorship was excellent and not dissimilar for both the OxZr and CoCr groups at 10 years. Therefore, with respect to implant longevity at the end of the first decade, there appears to be no clear advantage of OxZr heads compared to CoCr heads when paired with XLPE for patients with similar demographics. Further follow-up into the second and third decade may be required to demonstrate if a difference does exist

Background. There are few reports including natural course of initial gap in total hip arthroplasty. The purpose of this study is to investigate the incidence of initial gap in the PSL type shells and its natural course. Methods. Total of 386 THAs with Trident or TriAD PSL shells were performed between January 2000 and December 2014. Exclusion criteria were shells with screw fixations (n=189), previous pelvic osteotomy (n=15) and less than 3 years’ follow-up (n=11). Finally, our study included 171 hips. Average age was 56.8 (17∼83) years at THA and average follow-up time was 8.3 (3∼16.3) years; 112 (66%) were women; and 120 hips (70.2%) had osteoarthrosis. As radiographic evaluation, we checked presence or absence of initial gap, maximum size of it, gap filling and cup stability. The presence of initial gap was defined as gap present on post-operative anteroposterior X-ray measuring 1mm or greater. Gap filling was defined as confirmed trabecular formation between the cup and acetabular floor without cup migration. And we determined the time to gap filling. As clinical evaluation, we retrospectively checked Harris Hip Score (HHS) at pre-operative and final follow-up period, and presence of shell revision. Furthermore, we compared clinical results with or without initial gap. Results. Initial gap was confirmed at 85 hips (49.7%) and mean maximum size was 2.1 (1∼6.3) mm. Mean gap filling occurred at 2.5 (± 1.4) years and there was no unstable cup. Comparing clinical results with or without initial gap, pre-operative HHS was not significantly associated with initial gap (57.8 and 56.3, respectively, p=0.41). HHS at final follow-up period was also not significantly associated with initial gap (88.4 and 87.5, respectively, p=0.49). There was no shell revision with or without initial gap. Discussion. Initial gap of hemispherical type shell is reported that its incidence is 16∼38% and initial gap is not associated with clinical outcome. Our results show that PSL type shell occurs initial gap more frequently than hemispherical type shells. Conclusion. Initial gap of PSL type shell was confirmed at 85 hips (49.7%) and mean gap filling occurred at 2.5 years. Initial gap did not affect shell revision and clinical outcome

Introduction. Patients presenting with osteoarthritis as late sequelae following pediatric hip trauma have few options aside from standard Total Hip Replacement (THR). For younger more active patients, Hip Resurfacing Arthroplasty (HRA) can be offered as an alternative. HRA has been performed in the United States over the past decade and allows increased bone preservation, decreased hip dislocation rates versus THR, and potential to return to full activities. Patients presenting with end-stage hip arthritis as following prior pediatric trauma or disease often have altered hip morphology making HRA more complicated. Often Legg-Calve-Perthes (LCP) patients present with short, wide femoral necks, and femoral head distortion including coxa magna or coxa plana. There often can be acetabular dysplasia in conjunction with the proximal femoral abnormalities. Slipped Capital Femoral Epiphysis (SCFE) patients have an alteration of the femoral neck and head alignment, which can make reshaping the femoral head difficult. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. We present a cohort of 20 patients, with history of a childhood hip disorder (SCFE or LCP), who underwent HRA to treat end-stage arthritis. Fifty percent had prior pediatric surgical intervention at an average age of 11. Method. After Institutional Review Board approval, data was reviewed retrospectively on patients with pediatric hip diseases of SCFE and LCP who underwent HRA using the Birmingham Hip Resurfacing (BHR) by a single orthopaedic surgeon at a teaching institution. Harris Hip Scores (HHS), plain radiographs and blood metal ion levels were reviewed at routine intervals (12 months and annually thereafter). Those who had not returned for recent follow-up were contacted via telephone survey for a modified HHS. Results. Twenty patients had mean follow up of 2.8 years (range 1–7 years). Twelve had LCP and 8 SCFE. Median implant duration was 2.4 years. One-year metal ion testing revealed median chromium level of 2.3 ppb and median Cobalt level of 1.5 ppb. At one-year follow up, plain radiographs demonstrated all patient implants to be well-fixed, without radiolucent lines or osteolysis. Two patients at three and five-year follow-up exhibited heterotopic ossification. Mean HHS for LCP at 6 weeks post-operative was 88, and 98 at one year. Mean HHS for SCFE at 6 weeks post-operative was 77.5, and 98.6 at one year. LLD was significantly improved with an average pre-operative LLD of 12.6 mm and post op of 2.6 mm (p-value <0.001). At most recent follow-up, all retained their implants with overall average HHS of 98. Conclusion. At minimum of one-year following HRA, an increase in functional outcomes is found in patients who underwent HRA for osteoarthritis associated with LCP and SCFE with a mean HHS of 98. No increase was found in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure related to proximal femoral morphologic abnormalities, or presence of acetabular dysplasia [Fig 1]

INTRODUCTION. Cementless femoral component designs supplemented with hydroxyapatite (HA) coating have been hypothesised to enhance osseointegration, thereby improving stability and clinical outcomes. We herein offer interim results at 5 years from a prospective, multi-centre study of a femoral stem (SL-PLUS™ Hip Stem Prosthesis), forged from titanium alloy (Ti6Al7Nb) and consisting of a titanium plasma sprayed coating (0.3mm) with an additional 0.05mm layer of HA. METHODS. Investigators at 2 centres enrolled patients between 18–75 years of age who underwent primary total hip arthroplasty (THA) with this HA-coated stem. The study's primary outcome was the clinical efficacy of the stem, as measured by the Harris Hip Score (HHS), Western Ontario & McMaster Universities Osteoarthritis (WOMAC) Score calculated out of Hip Disability and Osteoarthritis Outcome Score (HOOS), and the EuroQol EQ-5D-3L index score and visual analogue scale (VAS). Its secondary outcomes included a radiographic assessment of implant position and fixation, and overall safety, as measured by intraoperative/early postoperative complications and survivorship calculated using Kaplan-Meier estimates. RESULTS. Ninety-three patients (94 hips) were enrolled in the study. At the time of surgery, the study population had a mean age of 60.1 years (standard deviation [SD], 8.4), a mean body mass index of 27.9 kg/m. 2. (SD, 4.75), and 54.8% were female. Indications for surgery include primary osteoarthritis (74.5%), dysplasia (17.5%), femoral head necrosis (6.4%), and other (2.1%). Patients were followed up through 5 years in the ongoing safety and performance analysis. Between preoperative baseline and final follow up, there were notable improvements in the mean scores for all primary clinical outcomes: HHS (51.6 to 91.4, respectively), WOMAC from HOOS (42.6 to 91.0, respectively), mean EQ-5D-3L index score (0.7 to 0.9, respectively), and EQ-5D-3L VAS (54.7 to 80.2, respectively). The majority of patients rated their satisfaction as excellent (84.2% of treated hips), with an additional 14.5% of treated hips being mostly satisfied. Five years after surgery, radiographic findings showed an overall stability of the device, with 100% unchanged stem positions (no movement in varus/valgus or subsidence) and no stem was classified as loose. Intraoperative complications were observed in 3 patients (3.2%), consisting of 2 cases of trochanteric fracture and 1 case of leg lengthening. There were no general early postoperative complications reported in any patient. Two revision surgeries of the study device were reported, both due to infection, resulting in a survivorship of 97.5% (95% confidence interval: 90.3% – 99.4%) at 5 years. CONCLUSION. These results confirm the safety and efficacy of this HA-coated femoral stem at 5 years. All clinical outcomes showed significant improvement between baseline and midterm follow up, with mean HHS in particular meeting the 90-point range considered “excellent.” Additionally, revision rates met the accepted benchmarks for a successful THA device. For any figures or tables, please contact authors directly

The study aimed to determine how well recorded pain levels and range of motion relate to patients' reported levels of functional ability/disability pre- and post- total hip arthroplasty. Range of motion (ROM), Oxford Hip Score (OHS) and Self-Report Harris Hip Score (HHS) were recorded pre-operatively and 3 months post-total hip arthroplasty. Pearson's correlation coefficients were calculated to determine the strength of the relationships both pre- and post-operatively between ROM (calculated using the HHS scoring system) and scores on OHS and HHS and response relating to pain from the questionnaires (question 1 HHS and questions 1, 6, 8, 10, 11 and 12 of OHS) and overall scores. Only weak relationships were found between ROM and HHS pre- (r = 0.061, n = 99, p = 0.548) and post-operatively (r = 0.373, n = 66, p = 0.002). Similar results were found for OHS, and when ROM was substituted for flexion range. In contrast, strong correlations were found between OHS pain component and HHS pre- (r = -0.753, n = 107, p<0.001) and post-operatively (r = -0.836, n = 87, p<0.001). Strong correlations were also found between the OHS pain component correlated with the HHS functional component only (HHS with score for questions relating to pain deducted) pre- (r = -0.665, n = 107, p<0.001) and post-operatively (r = -0.688, n = 87, p<0.001). Similar results were found when the HHS pain component was correlated with OHS. In orthopaedic clinical practice ROM is routinely used to assess the success or failure of arthroplasty surgery. These results suggest that this should not be done. Instead, asking the patient the level of pain that they are experiencing may be a good determinant of level of function. The results of this study may aid the development of arthroplasty scoring systems which better assess patients' functional ability

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

A matched comparison was made between femoral neck-preserving short, tapered stems (n = 50) and conventional length femoral stems (n = 50) in cementless total hip arthroplasty between January 2008 and January 2012. Patients were matched for age, sex, body mass index, height, surgical approach, and surgeon. In group A, mean preoperative HHS and WOMAC scores of 55.0 and 53.0, respectively, improved to mean postoperative scores of 98.6 and 3.3, respectively, at an average follow–up of 37.2 months. In group B, mean preoperative HHS and WOMAC scores of 53.0 and 49.5, respectively, improved to mean postoperative scores 97.8 and 4.4, respectively, at an average follow–up of 35.3 months. In addition, no significant differences in mean postoperative HHS (P = 0.168) or WOMAC scores (P = 0.158) were observed between the two groups according to the independent sample t-test. Table 1 shows two stems (4%) located in valgus (greater than 5° from neutral). The mean preoperative and postoperative HHS and WOMAC scores were similar to those of stems neutrally located in group A. All group A stems displayed bone bridging and endosteal spot welds distributed in Gruen zones 2 and 6 as evidence of bony ingrowth with no radiolucencies (Fig. 1). Two patients in group B had the slight decrease in bone density, mostly in Gruen zone 1 and 7. No radiographic evidence of osteolytic lesions, cortical hypertrophy, or acetabular fractures was detected in either group. Furthermore, no patient required revision surgery for aseptic loosening. The chi–square (Fisher's exact) test showed no significant difference between the two groups with respect to patient complications (Table 2). One patient in group A with a CCD angle of 135° had subsidence (greater than 2 mm, P =0.313) that displayed bony ingrowth with no further progression of subsidence at final follow-up. An intraoperative minor femur neck fracture (P =1.00) occurred in two patients (one in group A and one in group B). These patients were treated by cerclage wires without further incident. Three patients (two in group A: valgus and a CCD angle 135°, and one in group B: varus) had malalignment (P = 0.554) that was not associated with loosening. One patient in group A with a CCD angle of 135° had greater than 1 cm leg length discrepancy (shortening, P = 0.313). Two patients in group B had thigh pain (P = 0.151) that disappeared after a few months. Three patients (one in group A and two in group B) had heterotopic ossifications (P = 0.554) that were categorized as Brooker class I in two patients and class II in one patient without limiting their activities. In conclusion, no significant differences in the clinical and radiographic outcomes as well as component-specific complications were observed between the two groups, showing satisfactory performance at the 5-year follow-up. Group A had a higher incidence of malalignment and subsidence and a lower incidence of thigh pain and proximal bone resorption than group B

Introduction. Total Hip Arthroplasty (THA) is currently one of the most widely performed surgical procedures in clinical orthopaedic practice. Despite the recorded number of uncemented implants has steadily increased in recent years, cemented fixation still remains the benchmark in THA, accounting for most of the procedures performed nowadays. The Friendly Short is a novel cemented short-stem that grants a less invasive and more bone conservative approach due to its shortened height and innovative cementing technique. It is indicated to treat elderly patients with the aim of preserving bone diaphysis while decreasing postoperative recovery times. Its instrument set allows to optimize the cement mantle thickness via an improved pressurization and stem centralization system. Objectives. Aim of this prospective study was to evaluate functional recovery and implant stability after THA with this cemented short-stem. Methods. Between June 2011 and October 2012, 96 consecutive patients (100 hips) underwent THA with the Friendly Short stem (Lima Corporate). All patients received DELTA-PF cups with UHMWPE cross-linked liners and CoCrMo femoral heads (Lima Corporate). A minimally invasive postero-lateral surgical approach was used in all cases. There were 60 women and 36 men, with a mean age and BMI of 72.6 ± 6.2 (59–85) years and of 26.6 ± 3.9 (18.7–35.6) kg/m2. Most patients were retired (87%) and led a moderately active lifestyle (79%). Underlying pathology was mostly primary coxarthrosis (94%), followed by aseptic necrosis (AVN) (4%) and post-traumatic osteoarthritis (2%). Radiographic and clinical evaluation (Harris Hip Score HHS, Oxford Hip Score OHS) were performed preoperatively, and postoperatively, at 45 days, and at 6, 12, and 24 months. Results. Mean HHS and OHS improved from 36.0 ± 11.3 (7–57) and 10.9 ± 4.9 (0–24) preoperatively, to 96.4 ± 6.1 (78–100) and 46.5 ± 3.1 (33–48) at 2 years. Most significant improvements were recorded already at 45 days after surgery, with a mean HHS of 78.6 ± 9.9 (27–100) and a mean OHS of 34.0 ± 7.4 (18–48). Despite old age, all patients reported remarkable early recovery, especially in terms of joint functionality [Mean flexion: preoperative 77.7 ± 11.1 (40–90), 101.7 ± 8.9 (70–110) at 45 days] and pain relief [Mean HHS pain domain: preoperative 9.6 ± 4.2 (0–20), 41.4 ± 3.6 (20–44) at 45 days); mean OHS pain sub-domain: preoperative 0.2 ± 0.5 (0–4), 3.4 ± 0.8 (1–4) at 45 days)]. X-rays demonstrated good implant stability thanks to optimal cement fixation; there was only 1 case of non-progressive 1-mm radiolucent lines, but no osteolytic areas, subsidence or loosening were observed. Absence of fatigue fractures in the cement mantle proved that there was good stress distribution. Acetabular cups were all stable: only 1 case of non-progressive 1-mm radiolucent lines was reported, but no case of either sclerosis or osteolysis was observed. No revision or implant failure occurred up to 2-year follow-up. Conclusions. Clinical and patient-subjective outcomes were very satisfactory, indicating a significant early functional recovery. Although longer follow-up is required, radiographic assessment demonstrated good implant stability already at 2 years as result of this innovative cementing technique