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

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

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

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

Peri-prosthetic infection remains a leading cause of revision surgery. Recent publications from the American Musculoskeletal Infection Society have sought to establish a definition of peri-prosthetic infection based on clinical findings and laboratory investigations. The limitations of their approach are discussed and an alternative definition is proposed, which it is felt may better reflect the uncertainties encountered in clinical practice.

Introduction. Revision hip arthroplasty with massive proximal femoral bone loss remains challenging. Whilst several surgical techniques have been described, few have reported long term supporting data. A proximal femoral allograft (PFA) may be used to reconstitute bone stock in the multiply revised femur with segmental bone loss of greater than 8 cm. This study reports the outcome of largest case series of PFA used in revision hip arthroplasty. Methods. Data was prospectively collected from a consecutive series of 69 revision hip cases incorporating PFA and retrospective analyzed. Allografts of greater than 8 cm in length (average 14cm) implanted to replace deficient bone stock during revision hip surgery between 1984 and 2000 were included. The average age at surgery was 56 years (range 32–84) with a minimum follow up of 10 years and a mean of 15.8 years (range). Results. From the original cohort four patients had died with the original PFA, 21 (30.4%) patients required further surgery with 14 (20.3%) of these needing revisions of the femoral component. The mean time to femoral revision was 9.5 years and Kaplan-Meier survivorship analysis demonstrates a 79.9% PFA survivorship at 20 years. Discussion. Proximal femoral allograft affords long lasting reconstruction of the femoral component in revision hip surgery. We advocate PFA as an attractive option in the reconstruction of the hip in the presence of significant segmental bone loss in younger patients

Purpose. Tape blisters after hip surgery are frequent. There are source of pain, an obstacle for rapid rehabilitation and an open door for infection. Previous studies have shown a reduction up to 10% according to the type of bandage. A previous survey in our hospital demonstrated more than 50% of patients presenting tape blisters with the use of Hypafix. The purpose of this prospective study was to compare the prevalence of blisters with the use of three different kinds of bandages. Method. Between April and December 2009, 150 patients admitted for hip surgery (THR, hip fractures) were randomized in three groups: Hypafix (control group), silicone gel (Mepilex Border), perforated plaster (Mepore Pro). Groups were similar for demographic datas and type of surgery. Main outcome is tape blisters during hospital stay. Additional observations were duration of hospital stay, costs related to bandages and nursing cares. Outpatient records were completed by nurses and patients and returned to research team after complete wound healing. Results. 149 patients completed follow-up, one patient was excluded because of cancelled surgery. The blister prevalence in the silicone group is of 3% and significantly lower than the Mepore Pro (59%, p<0,01) and the Hypafix group (63%, p<0,01). Blisters appear in the first two days after surgery. There is no relationship with the type of surgery. Hospital stay was similar in all groups. 45% of outpatient records were obtained. Silicone gel bandage is cost effective: even if more expensive, it required less nursing cares during hospital stay and after returning home. Conclusion. The silicone gel bandage (Mepilex border) is associated with only 3% of tape blisters and really more effective than the two other bandages. It is even more effective than bandages described in the literature. It is also cost effective and doesnt require outpatient cares. The silicone bandage is associated with an important reduction of tape blisters after hip surgery, with the lower rate observed in the literature

Queen Elizabeth the Queen Mother Hospital, Margate, East Kent Hospitals NHS University Trust, UK. PURPOSE. Surfaces of supports used to position patients for hip replacement are usually are in direct contact with the patient skin around the groin/buttock areas & repeated use of same supports, in trauma & elective surgeries, can be a source of cross-infection & wound contamination. MATERIALS AND RESULTS. Swab samples from 12 supports, employed interchangeably for elective & trauma surgery. Cultured & incubated at 37 0 C in Columbia Blood Agar. 2 random supports cleaned using Sani Cloth Detergent non-alcoholic wipes & 2 samples were obtained from each support, 5 min later. 71% sampled supports were contaminated, with Coagulase-negative Staphylococcus, including Staph Epidermidis, being the most commonly grown organism with average of 5.3 colony forming units (CFU) (0-38) per swab. 5 min after cleaning 2 of above supports there was a 100% reduction in their contamination with no growth from the 4 swabs. CONCLUSION. Trauma patients are not necessarily subjected to groin MRSA swabs pre-operatively in contrast to patients undergoing elective hip surgery who are rigorously swabbed for the same & interchangeable use of hip supports in trauma and elective patients defeats the purpose of this practice considering the fact that Coagulase -ve Staphylococci like Staph epidermidis, reside on the hip supports presently used in the orthopaedic theatre. We recommend strict cleaning of these supports for 5 min with the detergent wipes before & between every orthopaedic hip case & where feasible, the supports used should be different for elective and trauma cases

Aim. Different perioperative strategies have been implemented to reduce the devastating burden of infection following arthroplasty. The use of iodophor-impregnated adhesive incise drapes is one such strategy. Despite its wide adoption, there is little proof that this practice leads to a reduction of bacterial colonization. The aim of this randomized, prospective study was to evaluate the efficacy of iodophor-impregnated adhesive drapes for reducing bacterial count at the incision site. Method. A total of 96 patients undergoing open joint preservation procedure of the hip were enrolled in this prospective, randomized clinical trial of iodophor-impregnated adhesive drapes. *. One half of patients (n=48) had iodophor-impregnated adhesive drapes. *. applied to the skin prior to incision and kept on throughout the procedure, while the other half (n=48) underwent the same surgery without the use of iodophor-impregnated adhesive drapes. *. Culture swabs were taken from the surgical site at five different time points during surgery (pre-skin preparation, after skin preparation, post-incision, before subcutaneous closure, and prior to dressing application) and sent for culture and colony counts. Mixed-effects and multiple logistic regression analyses were utilized. Results. Iodophor-impregnated adhesive drapes resulted in a significant reduction of bacterial colonization of the surgical incision. At the conclusion of surgery, 12.5% (6/48) of incisions with iodophor-impregnated adhesive drapes. *. and 27.0% (13/48) without adhesive drapes were positive for bacteria. When controlling for preoperative colonization and other factors, patients without adhesive drapes were significantly more likely to have bacteria present at the incision at the time of closure (odds ratio (OR) 11.88, 95% confidence interval (CI) 1.45–80.00), and at all time-points when swab cultures were taken (OR 2.48, 95% CI 1.00–6.15). Conclusions. Based on this skin sampling study, incise draping significantly reduces the rate of bacterial colonization/contamination during hip surgery. The bacterial count at the skin was extremely high in some patients without iodophor-impregnated adhesive drapes. *. , which raises the possibility that a subsequent surgical site infection or periprosthetic joint infection could likely arise if an implant had been utilized

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively. In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant. In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery. In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery

Total hip replacement in Germany has been performed in 227293 cases in 2015 and tendency is increasing. Although it is a standard intervention, freehand positioning of cup protheses has frequently poor accuracy. Image-based and image-free navigation systems improve the accuracy but most of them provide target positions as alphanumeric values on large-size screens beneath the patient site. In this case the surgeon always has to move his head frequently to change his eye-focus between incision and display to capture the target values. Already published studies using e.g. IPod-based displays or LED ring displays, show the chance for improvement by alternative approaches. Therefore, we propose a novel solution for an instrument-mounted small display in order to visualise intuitive instructions for instrument guidance directly in the viewing area of the surgeon.

For this purpose a solution consisting of a MicroView OLED display with integrated Arduino microcontroller, equipped with a Bluetooth interface as well as a battery has been developed. We have used an optical tracking system and our custom-designed navigation software to track surgical instruments equipped with reference bodies to acquire the input for the mini-display. The first implementation of the display is adapted to total hip replacement and focuses on assistance while reaming the acetabulum. In this case the reamer has to be centred to the middle point of the acetabular rim circle and its rotation axis must be aligned to the acetabular centre axis by Hakki. By means of these references the actual deviations between instrument and target pose are calculated and indicated. The display contains a cross-hair indicator for current position, two bubble level bars for angular deviation and a square in square indicator for depth control. All display parts are furnished with an adaptive variable scale. Highest possible resolution is 0.5 degrees angular, 1 millimeter for position and depth resolution is set to 2 mm.

Compared to existing approaches for instrument-mounted displays, the small display of our solution offers high flexibility to adjust the mounting position such that it is best visible for the surgeon while not constraining instrument handling. Despite the small size, the proposed visualisation symbols provide all information for instrument positioning in an intuitive way.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

Not all total hip arthroplasty cases are created equal is a maxim that holds true for both primary and revision scenarios. Complex cases involve patients presenting with compromised bone and/or soft tissue. For primary cases, these include hips with dysplasia, ankylosis, deformed proximal femora, protrusio acetabuli, prior hip fracture with or without failed fixation, previous bony procedures, or neuromuscular conditions. In revision surgery, complex scenarios include cases compromised by bone loss, deterioration of the soft tissues and resulting in dislocation and instability, peri-prosthetic fracture, leg length discrepancy, infection, and more recently, hypersensitivity reactions. Meticulous surgical technique including component placement is essential. In this interactive session, a moderator and team of experts will discuss strategies for evaluation and management of a variety of challenging hip case scenarios.

Background

The use of tranexamic acid (TEA) can significantly reduce the need for allogenic blood transfusions in elective primary joint arthroplasty. Revision total hip arthroplasty requires increased utilization of post-operative blood transfusions for acute blood loss anemia compared to elective primary hip replacement. There is limited literature to support the routine use of TEA in revision THA.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected hip arthroplasty experts. The primary cases will include challenges such as hip dysplasia, altered bony anatomy and fixation challenges. In the revision hip arthroplasty scenarios issues such as bone stock loss, leg length discrepancy, instability and infection will be discussed. This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

Methods

A pericapsular approach was used with capsulotomy and then correction of the lesions both in the pelvic and in the femoral aspects. The traction times and total surgery times for the conventional method and the new out-inside technique were compared.

Not all total hip arthroplasty cases are created equal is a maxim that holds true for both primary and revision scenarios. Complex cases involve patients presenting with compromised bone and/or soft tissue. For primary cases, these include hips with dysplasia, ankylosis, deformed proximal femora, protrusio acetabuli, prior hip fracture with or without failed fixation, previous bony procedures, or neuromuscular conditions. In revision surgery, complex scenarios include cases compromised by bone loss, deterioration of the soft tissues and resulting instability, periprosthetic fracture, leg length discrepancy, infection, and more recently, hypersensitivity reactions. In this interactive session, a moderator and team of experts will discuss strategies for evaluation and management of a variety of challenging hip case scenarios.