Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications. Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled. We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters. Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices

Aim. Left sided hip fractures are more common but no obvious cause has been identified. Left handedness has previously been associated with an increased risk of fracture for a number of sites but to the best of our knowledge no association between handedness and hip fracture has previously been reported. Methods. 2 separate 6-month prospective reviews of hip fracture patients aged over 65 years-of-age were conducted at 2 different hospitals. Handedness was dete2rmined at the time of admission. The second review focused on the use of walking aids. Patients with a previous cerebrovascular accident, neurological condition or contralateral hip prosthesis were excluded due to increased balance problems and falls risk. Results. Hand dominance was recorded for 339 patients; 304 right and 35 left. 91 patients were excluded. Of the remaining 248 patients more than twice as many (2.06 times) fractured their hip on the side of their non-dominant hand. For left handed individuals this increased to 4.6 times. Walking aid use was recorded for 102 patients. For patients using no walking aids, a Zimmer frame or 2 walking sticks; equal numbers of patients sustained right and left hip fractures. While 97.7% of patients using 1 walking stick did so in their dominant hand, sustaining 84% contralateral hip fractures. Conclusions. The direction in which people fall and the causes of hip fractures are clearly multi-factorial. However there is a clear association between hand dominance and the side of hip fracture, particularly in left handed individuals. Walking aids also play a role with 97.7% of patients using a walking stick in their dominant hand resulting in 84% contralateral hip fractures. By being aware of this association it may be possible to target both patient education and physiotherapy potentially reducing the number of patient falls and associated hip fractures

Pelvic discontinuity is a separation through the acetabulum with the ilium displacing superiorly and the ischium/pubis displacing inferiorly. This is a biomechanically challenging environment with a high rate of failure for standard acetabular components. The cup-cage reconstruction involves the use of a highly porous metal cup to achieve biological bone ingrowth on both sides of the pelvic discontinuity and an ilioischial cage to provide secure fixation across the discontinuity and bring the articulating hip center to the correct level. The purpose of this study was to report long term follow up of the use of the cup-cage to treat pelvic discontinuity. All hip revision procedures between January 2003 and January 2022 where a cup-cage was used for a hip with a pelvic discontinuity were included in this retrospective review. All patients received a Trabecular Metal Revision Shell with either a ZCA cage or TMARS cage (Zimmer-Biomet Inc.). Pelvic discontinuity was diagnosed on pre-operative radiographs and/or intraoperatively. Kaplan-Meier survival analysis was performed with failure defined as revision of the cup-cage reconstruction. Fifty-seven cup-cages in 56 patients were included with an average follow-up of 6.25 years (0.10 to 19.98 years). The average age of patients was 72.09 years (43 to 92 years) and 70.2% of patients were female. The five year Kaplan-Meier survival was 92.0% (95% CI 84.55 to 99.45) and the ten year survival was 80.5% (95% CI 58.35 to 102.65). There were 5 major complications that required revision of the cup-cage reconstruction (3 infections and 2 mechanical failures). There were 9 complications that required re-operation without revision of the cup-cage reconstruction (5 dislocations, 3 washouts for infection and one femoral revision for aseptic loosening). In our hands the cup-cage reconstruction has provided a reliable tool to address pelvic discontinuity with an acceptable complication rate

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols

Total Hip Arthroplasty (THA) surgery is a physical and cognitive challenge for surgeons. Data on stress levels, cognitive and physical load of orthopaedic surgeons, as well as ergonomic impact, are limited. With and without the use of an automated impaction device, operational efficiency and the surgeon's ergonomic, mental, and physical load was investigated. In a total of thirty THA procedures, a standard manual technique was compared with an automated impaction device. Three computerized cognitive tasks (Simon, pattern comparison, and pursuit rotor) and five physical tests (isometric wall-sit, plank-to-fatigue, handgrip, supra-postural task, and shoulder endurance) were used to assess psychophysiological load of the surgeon. Surgeon's cortisol concentration was evaluated from saliva samples. Postural risk was assessed by Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Efficiency was assessed by timing surgical steps and instrumentation flow. Cognitive performances after automated impaction showed faster response times and lower error rates with a greater time-on-target (+1.5 s) and a lower mouse deviation from target (−1.7 pixels). Manual impaction showed higher physical exhaustion in the isometric wall-sit test (10.6% vs. 22.9%), plank-to-fatigue (2.2% vs. 43.8%), the number of taps in the supra-postural task (−0.7% vs. −7.7%), handgrip force production in the dominant (−6.7% vs. −12.7%) and contralateral hand (+4.7% vs. +7.7%), and in shoulder endurance (−15s vs. −56s). An increase of 38.2% in salivary cortisol concentration between the midday (1.31 nmol/l) and afternoon session (1.81 nmol/l) was observed with manual impaction. After using automated impaction, salivary cortisol concentration decreased (−51.2%). Manual broaching time was on average 6′20’’ versus 7’3’’ with automated impaction. RULA of manual impaction scored 6 for cup impaction and 5 for femoral broaching, versus 3 and 3 for automated impaction, respectively. REBA of manual impaction scored 9 for cup impaction and 5 for femoral broaching, versus 4 and 3 for automated impaction, respectively. Automated impaction lowers surgeons’ cognitive and physical fatigue and leads to reduced stress and improved ergonomics without loss of surgical efficiency

Aims. Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. Methods. In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. Results. Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation. Conclusion. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206–211

The clinical success of THA is accepted, however wide variation in implant usage and outcomes is reported across the world. The Getting It Right First Time initiative in the UK has recommended increased use of cemented constructs in patients over 70. A clear clinical directive has been proposed aiming to reduce revision rates, improve outcomes and increase cost effectiveness. This study compares the outcomes of cemented, hybrid and cementless THA from a high-volume single center at long-term follow-up. A prospective database identified 1,699 cemented, 5,782 hybrid and 2,631 cementless THAs. Mean follow-up was 8.1 years, 5.3 years and 6.3 years respectively. Primary endpoint was revision for any reason. 47 (1.79%) cemented, 93 (1.60%) hybrid and 39 (1.48%) cementless THAs underwent revision. The difference in overall revision rate was statistically significant (P=0.002). Mean time to revision was 4.5 years in the cemented group, 2.1 years in the hybrid group and 2.6 years in the cementless group. 1 year survivorship was 99.2% in the cemented group, 99.0% in the hybrid group and 98.9% in the cementless group. 3 year survivorship was 98.6% in the cemented group, 98.8% in the hybrid group and 98.9% in the cementless group. At 10 years it was 97.0%, 97.6% and 97.9% respectively. (Difference not statistically significant (p=0.09). Of relevance cemented fixation showed the lowest 10-year survivorship in patients over 70, over 75 and over 80. (not statistically significant P=0.5, 0.6 and 0.47 respectively). In a high-volume center, excellent outcomes were achieved at 10 years with all three constructs. Cemented THA had the lowest survivorship compared to hybrid, then cementless fixation. Cemented fixation did not outperform cementless fixation in any age group. Surgeons should monitor their outcomes. Use of a philosophy that works best in their own hands should be supported

Aims

Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.

Aims. Accurate placement of the acetabular component during total hip arthroplasty (THA) is an important factor in the success of the procedure. However, the reported accuracy varies greatly and is dependent upon whether free hand or navigated techniques are used. The aim of this study was to assess the accuracy of an instrument system that incorporates 3D printed, patient-specific guides designed to optimise the placement of the acetabular component. Patients and Methods. A total of 100 consecutive patients were prospectively enrolled and the accuracy of placement of the acetabular component was measured using post-operative CT scans. Results. The mean absolute deviation from the planned inclination and anteversion was 3.9° (0.0° to 13.6°) and 3.6° (0.0° to 12.9°), respectively. In 91% of cases the planned target of +/-10° was achieved for both inclination and anteversion. Conclusion. Accurate placement of the acetabular component can be achieved using patient-specific guides and is superior to free hand techniques and comparable to navigated and robotic techniques. Cite this article: Bone Joint J 2016;98-B:1342–6

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Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

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Several different designs of hemiarthroplasty are used to treat intracapsular fractures of the proximal femur, with large variations in costs. No clinical benefit of modular over monoblock designs has been reported in the literature. Long-term data are lacking. The aim of this study was to report the ten-year implant survival of commonly used designs of hemiarthroplasty.

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Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury.

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When performing revision total hip arthroplasty using diaphyseal-engaging titanium tapered stems (TTS), the recommended 3 to 4 cm of stem-cortical diaphyseal contact may not be available. In challenging cases such as these with only 2 cm of contact, can sufficient axial stability be achieved and what is the benefit of a prophylactic cable? This study sought to determine, first, whether a prophylactic cable allows for sufficient axial stability when the contact length is 2 cm, and second, if differing TTS taper angles (2° vs 3.5°) impact these results.

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The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures.

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Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

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Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients.

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This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

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Although the Fitmore Hip Stem has been on the market for almost 15 years, it is still not well documented in randomized controlled trials. This study compares the Fitmore stem with the CementLeSs (CLS) in several different clinical and radiological aspects. The hypothesis is that there will be no difference in outcome between stems.

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The aim of this study was to evaluate the reliability and validity of a patient-specific algorithm which we developed for predicting changes in sagittal pelvic tilt after total hip arthroplasty (THA).

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Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients.