The Bernese periacetabular osteotomy (PAO) is not indicated for growing hips as it crosses the triradiate cartilage in its posterior branch, and experimental work has shown this can induce substantial deformations, similar to posttraumatic dysplasia, which is observed after pelvis crash injuries in childhood. Upon examination, all injuries in the 19 cases of posttraumatic dysplasia described in literature plus 16 hips of our personal collection took place before the age of 6, which is striking as pelvic injuries in children increase with age. Based on this observation, we started to extend the PAO indication to severe dysplasias in children with open growth plate, initially aged 9 years and older. Following the positive results, it was extended further, our youngest patient being 5 years old. We retrospectively examined radiographic outcomes of 23 hips (20 patients), aged 10.6±1.8 years [range 5.0 – 13.2], operated by us in four centers. Pre- and 3-months postoperative, and the latest FUP radiograph at growth plate closure were measured. We evaluated the acetabular index (AI), lateral center-edge (LCE), ACM-value and compared them with reference values adjusted for age. The age at triradiate cartilage closure was compared with the non-operated side. The follow-up time was 5.4±3.7 years [0.8 - 12.7]. In 5 hips, growth plate closure was delayed by a few months. All angles significantly normalized after PAO (LCE: 14±8° → 38±11°, AI: 20±8° → 7±4°, ACM: 53±5° → 48±4°), with >80% of them severe pathological pre-PAO, none afterwards. Acetabular molding was normal. Only few complications occurred; one had signs of coxarthosis, one sciatic nerve pain, one interfering osteosynthesis material that was removed, one had an additional valgus osteotomy, and all resolved. Based on 20 cases with follow-up until complete triradiate cartilage closure, we believe to have sufficient information to extend the PAO indication to growing hips of 9 years and older

Introduction. Open and arthroscopic hip debridement may be used for treatment of femoral acetabular impingement (FAI). There is a paucity of evidence regarding the efficacy of one over the other. Aim. To compare survivorship in terms of further surgical procedure at five years, in patients having undergone either arthroscopic or open hip debridement. Methods. Using our institutional database, we identified all post learning curve arthroscopic and open hip debridement cases with five years of follow up. Patients were matched based on age, gender and Tonnis grade. The primary outcome measure was 5 year survivorship to total hip arthroplasty (THA). Secondary outcome measures included 5 year survivorship to further (non THA) procedures on the joint. Radiological parameters were analysed including femoral neck version, sourcil, centre-edge and alpha angles. Results. A total of 390 arthroscopic and 1316 open operations were identified. Following exclusion and matching 102 (62 female, 39 male) cases were available for analysis in each group. Mean age was 36 years (range 17–51). At 5 years 14.8% of arthroscopic debridement patients and 5.9% of open debridement patients had undergone THA (p =0 .038). There was no statistical difference in secondary outcome measures. Discussion. A significantly higher percentage of patients undergoing arthroscopic debridement went on to THA when compared to matched patients receiving open debridement. We acknowledge the limitations of this study. However, despite the increasing prevalence of arthroscopic surgery to treat FAI, our results would suggest that open debridement may still remain the gold standard intervention. Further investigation, ideally in the form of an RCT, is warranted. Conclusion. In our case matched series, despite the longer rehabilitation and greater soft tissue insult, open surgery for FAI was associated with significantly less patients progressing to THA within 5 years compared to those undergoing arthroscopic debridement

Aims. Cam and pincer morphologies are potential precursors to hip osteoarthritis and important contributors to non-arthritic hip pain. However, only some hips with these pathomorphologies develop symptoms and joint degeneration, and it is not clear why. Anterior impingement between the femoral head-neck contour and acetabular rim in positions of hip flexion combined with rotation is a proposed pathomechanism in these hips, but this has not been studied in active postures. Our aim was to assess the anterior impingement pathomechanism in both active and passive postures with high hip flexion that are thought to provoke impingement. Methods. We recruited nine participants with cam and/or pincer morphologies and with pain, 13 participants with cam and/or pincer morphologies and without pain, and 11 controls from a population-based cohort. We scanned hips in active squatting and passive sitting flexion, adduction, and internal rotation using open MRI and quantified anterior femoroacetabular clearance using the β angle. Results. In squatting, we found significantly decreased anterior femoroacetabular clearance in painful hips with cam and/or pincer morphologies (mean -11.3° (SD 19.2°)) compared to pain-free hips with cam and/or pincer morphologies (mean 8.5° (SD 14.6°); p = 0.022) and controls (mean 18.6° (SD 8.5°); p < 0.001). In sitting flexion, adduction, and internal rotation, we found significantly decreased anterior clearance in both painful (mean -15.2° (SD 15.3°); p = 0.002) and painfree hips (mean -4.7° (SD 13°); p = 0.010) with cam and/pincer morphologies compared to the controls (mean 7.1° (SD 5.9°)). Conclusion. Our results support the anterior femoroacetabular impingement pathomechanism in hips with cam and/or pincer morphologies and highlight the effect of posture on this pathomechanism. Cite this article: Bone Jt Open 2021;2(11):988–996

Aims

This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD.

Introduction. Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short term outcomes, longer term outcomes are more sparsely reported. We aim to assess survivorship and functional outcome at ten years, in patients who have undergone open hip debridement. Patients/Materials & Methods. All patients who had undergone open debridement surgery were identified on our database. The electronic, radiographic and paper records were reviewed. Demographic data, radiological and operative findings were recorded. All patients underwent ten year review with a standardised AP hips radiograph, questionnaire, non-arthritic hip score (NAHS), oxford hip score (OHS) and SF12 score. Results. A total of 1626 operations were identified of which 37 had reached the tenth anniversary of their surgery. There were 14 females and 22 males. The average age was 41. 10 (45%) had undergone subsequent hip arthroplasty. Those who underwent hip arthroplasty were older at initial surgery than those who survived. However, this was not statistically significant (p= 0.127). Those who failed had a higher Tonnis and UCLA grade at time of surgery. The majority failed within the first 2 years. In those whose hip survived, the average NAHS was 87. 100% of survivors deemed there surgery to have been worthwhile. Discussion. These results represent the first cohort of our patients to reach ten year follow up. The results represent a learning curve in patient selection. It is unsurprising that those with more arthritic change were more likely to fail. Conclusion. In patients with clearly defined CAM impingement without joint space narrowing, open hip debridement remains an operation with worthwhile outcomes at ten years

Introduction. Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short-term outcomes, longer term outcomes are more sparsely reported. Patients/Materials & Methods. Patients who had undergone this surgery were identified on our database. Electronic, radiographic and paper records were reviewed. Demographic data, radiological and operative findings were recorded. Patients underwent ten-year review with standardised AP hip radiographs, questionnaire, non-arthritic hip (NAHS), Oxford hip (OHS) and SF-12 scores. Results. A total of 1626 operations were identified of which 183 had reached the tenth anniversary of their surgery. There were 91 females and 92 males. The average age was 39. Kaplan-Meier analysis indicated an overall 78% survival at ten years. However, once the learning curve was accounted for, by excluding the first year's cohort of patients, the survival rate was 84% at 10 years. Those who underwent hip arthroplasty were older at initial surgery and had a higher Tonnis grade than those who survived. The majority failed within the first 2 years. Labral repair, restoration of a normal centre edge angle and adequate CAM correction were associated with better survival. In those whose hip survived, the average NAHS and OHS were 87 and 39 respectively. 15% required further non-arthroplasty surgery (scope/revision) and 51% underwent trochanteric screw removal. 89% of survivors deemed their surgery to have been worthwhile at ten year follow up. Discussion. These results represent the first cohorts of our patients to reach ten year follow up. The results represent a learning curve in patient selection. It is unsurprising that those with more arthritic change were more likely to fail. Conclusion. In patients with clearly defined CAM impingement without joint space narrowing and where successful resection of the CAM and restoration of a normal centre edge angle can be achieved open hip debridement remains an operation with worthwhile outcomes at ten years

Introduction. Hip abductor tendon tears have been referred to as “rotator cuff tears of the hip,” and are a recognized etiology for persistent, often progressive, lateral hip pain, weakness, and limp. Multiple repair techniques and salvage procedures for abductor tendon tears have been reported in the literature; however, re-tear remains a frequent complication following surgical repair. This study compares the short-term outcomes of open abductor tendon repairs with decortication and suture fixation (DSF) compared to a modified technique repair into a bone trough (BT), to determine best surgical results for large abductor tendon avulsions. Additionally, surgical treatment of small tears versus large tears was examined. Methods. The outcomes of 37 consecutive hip abductor tendon repairs treated between January 2009 and December 2017 were retrospectively reviewed. Large tears were defined as detachment of 33–100% of the gluteus medius insertion. There were 15 DSF and 10 BT cases. Postoperative pain, ability to perform single leg stance, hip abduction, and Trendelenburg lurch, were examined. Small tears (12 cases) were defined as having no gluteus medius avulsion from the trochanteric insertion and were comprised of longitudinal tears (repaired side-by-side) and isolated gluteus minimus tears (repaired by tenodesis to the overlying gluteus medius). Standard statistical analyses were utilized. Type I error for all analyses was set at α=0.05. Results. When comparing large tear repair outcomes, repairs into a BT had superior outcomes to repairs with DSF: 0 (BT) versus 6 (DSF, 40%) failure rate (p<0.05), and greater reductions in pain at one-year post surgery (Δ VAS: BT, −5.70±0.97 | DSF: −2.73±0.69; p<0.01), ability to perform a single leg stance and hip abduction (90% and 100% vs 47% and 73%) (p<0.05). Clinical strength ratings were higher for repairs into a BT, but this did not reach statistical significance. When comparing large to small tear repair outcomes, small tears were found to have lower VAS pain scores and higher clinical strength ratings during both the pre-op and 1-year post-op time points (p<0.05). A higher percentage of those with small tears were able to perform a single leg stance and hip abduction (100%) compared to those with large tears (64% and 78% respectively) (p<0.05). A significantly higher frequency of residual lurch was also observed for those with large tears; 56% compared to small tears at 0%. Conclusions. Utilizing a BT repair significantly improved surgical results for large abductor tendon avulsions. Level of evidence: Therapeutic level IV case series

Aims. The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome. Methods. Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome. Results. At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI. Conclusion. FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes. Cite this article: Bone Jt Open 2022;3(10):804–814

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery. We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip. Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially. The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller. By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm)

Gluteal Tendinopathy is a poorly understood condition that predominantly affects post-menopausal women. It causes lateral hip pain, worse when lying on the affected side or when walking up a hill or stairs. It has been labelled ˜Greater Trochanteric Pain Syndrome” a name that recognises the lack of understanding of the condition. Surgical reconstruction of the gluteal cuff is well established and has been undertaken numerous times over the last 16 years by the senior author (AJL). However, the quality of collagen in the tendons can be very poor and this leads to compromised results. We present the results of gluteal cuff reconstruction combined with augmentation using a bioinductive implant. 14 patients (11 female, 3 male; mean age 74.2 ± 6.3 years) with significant symptoms secondary to gluteal tendinopathy that had failed conservative treatment (ultrasound guided injection and structured physiotherapy) underwent surgical reconstruction by the senior author using an open approach. In all cases the iliotibial band was lengthened and the trochanteric bursa excised. The gluteal cuff was reattached using Healicoil anchors (3–5×4.75mm anchors; single anchors but double row repair) and then augmented using a Regeneten patch. Patients were mobilised fully weight bearing post-operatively but were asked to use crutches until they were no longer limping. All had structured post-surgery rehabilitation courtesy of trained physiotherapists. There were no post-operative complications and all patients reported an improvement in pain levels (Visual Analogue Scale 7.8 pre-op; 2.6 post-op) and functional levels (UCLA Activity Score 3.5 pre-op; 7.1 post-op) at 6 months post surgery. Surgery for gluteal tendinopathy produces good outcomes and the use of Regeneten as an augment for poor quality collagen is seemingly a safe, helpful addition. Further comparative studies would help clarify this

Acetabular retroversion (ARV) is a cause of femoroacetabular impingement leading to hip pain and reduced range of motion. We aimed to describe the radiological criteria used for diagnosing ARV in the literature and report on the outcomes of periacetabular osteotomy (PAO) and hip arthroscopy (HA) in its management. A systematic review using PRISMA guidelines was conducted on the MEDLINE, CINAHL, EMBASE, COCHRANE database in December 2022. English-language studies reporting outcomes of PAO, or open or arthroscopic interventions for ARV were included. From an initial 4203 studies, 21 non-randomised studies met the inclusion criteria. Eleven studies evaluated HA for ARV, with average follow-up ranging from 1 to 5 years, for a cumulative number of 996 patients. Only 3/11 studies identified ARV using AP standardized pelvic radiographs. The most frequent signs describing ARV identified were: Ischial Spine Sign (98% of patients), Posterior Wall Sign (PWS, 94%) and Crossover Sign (COS, 64%); with mean Acetabular Retroversion Index (ARI) ranging from 33% to 35%. 39% of HA patients had all three radiographic signs. Clinically significant outcomes were reached by 33–78% of patients. Eight studies evaluated PAO for ARV, with a follow-up ranging from 2 to 10 years, for a cumulative number of 379 patients. Five of the eight studies identified ARV using standardized radiographs. ISS, COS and PWS were positive in 54%, 97% and 81% of patients, respectively with 52% of PAO patients having all three radiographic signs. Mean ARI ranged from 36–41%. Clinically significant results were reported in 71%–78% of patients. The diagnostic criteria for ARV is poorly defined in the literature, and the quality of evidence is low. Studies on HA are more likely to have used lenient diagnostic criteria. It remains difficult to recommend which cases maybe more suitable for treatment by HA rather than PAO

The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation. With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key. This study assesses the validity of the NHFS in predicting mortality after fragility DFFs. A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases. Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded. All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT. Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk. 285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes. 30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively. Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714). The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF

Aims. The frequency of severe femoral retroversion is unclear in patients with femoroacetabular impingement (FAI). This study aimed to investigate mean femoral version (FV), the frequency of absolute femoral retroversion, and the combination of decreased FV and acetabular retroversion (AR) in symptomatic patients with FAI subtypes. Methods. A retrospective institutional review board-approved observational study was performed with 333 symptomatic patients (384 hips) with hip pain due to FAI evaluated for hip preservation surgery. Overall, 142 patients (165 hips) had cam-type FAI, while 118 patients (137 hips) had mixed-type FAI. The allocation to each subgroup was based on reference values calculated on anteroposterior radiographs. CT/MRI-based measurement of FV (Murphy method) and AV were retrospectively compared among five FAI subgroups. Frequency of decreased FV < 10°, severely decreased FV < 5°, and absolute femoral retroversion (FV < 0°) was analyzed. Results. A significantly (p < 0.001) lower mean FV was found in patients with cam-type FAI (15° (SD 10°)), and in patients with mixed-type FAI (17° (SD 11°)) compared to severe over-coverage (20° (SD 12°). Frequency of decreased FV < 10° was significantly (p < 0.001) higher in patients with cam-type FAI (28%, 46 hips) and in patients with over-coverage (29%, 11 hips) compared to severe over-coverage (12%, 5 hips). Absolute femoral retroversion (FV < 0°) was found in 13% (5 hips) of patients with over-coverage, 6% (10 hips) of patients with cam-type FAI, and 5% (7 hips) of patients with mixed-type FAI. The frequency of decreased FV< 10° combined with acetabular retroversion (AV < 10°) was 6% (8 hips) in patients with mixed-type FAI and 5% (20 hips) in all FAI patients. Of patients with over-coverage, 11% (4 hips) had decreased FV < 10° combined with acetabular retroversion (AV < 10°). Conclusion. Patients with cam-type FAI had a considerable proportion (28%) of decreased FV < 10° and 6% had absolute femoral retroversion (FV < 0°), even more for patients with pincer-type FAI due to over-coverage (29% and 13%). This could be important for patients evaluated for open hip preservation surgery or hip arthroscopy, and each patient requires careful personalized evaluation. Cite this article: Bone Jt Open 2022;3(7):557–565

Aims. This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads. Methods. In all, six 28 mm and six 36 mm titanium stem-cobalt chrome head pairs with polyethylene sockets were tested in a novel instrumented hip simulator. Samples were tested using simulated gait data with incremental increasing loads to determine corrosion onset load and electrochemical activity. Half of each head size group were then cycled with simulated gait and the other half with gait compression only. Damage was measured by area and maximum linear wear depth. Results. Overall, 36 mm heads had lower corrosion onset load (p = 0.009) and change in open circuit potential (OCP) during simulated gait with (p = 0.006) and without joint movement (p = 0.004). Discontinuing gait’s joint movement decreased corrosion currents (p = 0.042); however, wear testing showed no significant effect of joint movement on taper damage. In addition, 36 mm heads had greater corrosion area (p = 0.050), but no significant difference was found for maximum linear wear depth (p = 0.155). Conclusion. Larger heads are more susceptible to taper corrosion; however, not due to frictional torque as hypothesized. An alternative hypothesis of taper flexural rigidity differential is proposed. Further studies are necessary to investigate the clinical significance and underlying mechanism of this finding. Cite this article: Bone Jt Open 2021;2(11):1004–1016

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures

Aims. Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck. Methods. A Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed. Results. Quantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens. Conclusion. Calcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients. Cite this article: Bone Jt Open 2021;2(8):611–617

Aims. Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods. A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. Results. VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (. sd. 3) vs 12 (. sd. 3)), were 12° more accurate in component orientation (mean error 4° (. sd. 6°) vs 16° (. sd. 17°)), and were 18% faster (mean 42 minutes (. sd. 7) vs 51 minutes (. sd. 9)). Conclusion. Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592

Aims. A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients. Methods. TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA. Results. A total of 534 patients were randomized, with 233 in group 1, 235 in group 2, and 66 in group 3; 92 patients (17.2%) were considered high-risk. The mean IBL did not differ significantly between the two intervention groups (848.4 ml (SD 463.8) for group 1, and 843.7 ml (SD 478.7) for group 2; mean difference -4.7 ml (95% confidence interval -82.9 to 92.3); p = 0.916). No differences in mortality or incidence of VTE were observed between any group. Conclusion. The addition of oral TXA for 24 hours postoperatively does not reduce blood loss beyond that achieved with a single 1 g IV perioperative dose alone. There may be a clinically relevant difference in patients with a normal BMI, which warrants further investigation. Critically, there were no safety issues in patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(7):1197–1205

To compare complications, survivorship and results in 2 groups of Furlong-HAP Active, one with ceramic-ceramic and the other with metal-XLPE friction pair. Prospective, non-randomized, comparison of 2 series of JRI uncemented prosthesis, implanted with identical protocol by 1 surgeon in 1 hospital from 2006 to 2014. Friction pair was ceramic (Biolox Forte or Delta) in 35 patients of 53.7+/−10.6 years (25–69) (21 males, 60%), and CrCo-XLPE in 65 cases of 69.0+/−8.9 years (42–81) (36 males, 55%); there were significant differences in age (p<0.00001) but not in sex (p=0.6565). Head diameter: Ce-Ce with 19 of 28mm, 9 of 32 and 7 of 36mm; Me-PE with 63 of 28mm, 1 of 32 and 1 of 36. Follow-up averaged 10.5+/−3.1 years (1–15) in ceramic and 9.8+/−3.8 years (2–15) in XLPE group. Pearson, Fisher, Kolmogorov-Smirnov, Student, Mann-Whitney, calculated with the informatic tools Microsoft Excel 2007 and . https://www.socscistatistics.com/tests/. . Complications in ceramic joints: 2 late infections (Fisher exact test=0.6101) (1 DAIR, 1 one-stage exchange); 1 dislocation (Fisher exact test=0.2549) (closed reduction); 1 Vancouver C fracture (ORIF) (Fisher exact test=0.6548). Complications in Me-XLPE joints: 2 late infections (Fisher=0.6101) (1 DAIR, 1 two-stage exchange); 7 dislocations (Fisher=0.2549) (2 early, open reduction) (5 late: 3 closed reduction, 1 cup revision, 1 constrained cup); 4 Vancouver B fractures (Fisher=0.6548) (2 intraoperative, cerclages; 2 late, exchange). Final follow-up: Harris Hip Score averaged 93.2+/−13.7 (23–100) in ceramic and 94.3+/−8.7 (65–100) in XLPE joints (p=0.64552). Wear: 0.06+/−0.38mm (0–1.5) in ceramic and 0.16+/−0.5mm (0–2) in Me-PE THAs (p=0.30302). Osteolysis in Charnley-De Lee zones: 8 zones (6 patients) (17%) in ceramic cups, 25 zones (15 patients) (23%) in XLPE cups (p=0.980127). Survivorship without any surgery or closed reduction after 15 years: 91.0% in ceramic joints, 83.8% in Me-XLPE joints. Survivorship without component exchange after 15 years: 93.9% in ceramic joints, 93.6% in Me-XLPE joints. At least after 10 years follow-up of Furlong-HAP Active, metal-XLPE and ceramic-ceramic joints present no significant differences in complications, clinical score, wear, acetabular osteolysis, or survivorship without component exchange. On the contrary, survivorship without any surgery or closed reduction is different because of the high rate of dislocation in 28mm metal-poly joints