Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort. Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach. After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001). While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns

Aims. In order to prevent dislocation of the hip after total hip arthroplasty (THA), patients have to adhere to precautions in the early post-operative period. The hypothesis of this study was that a protocol with minimal precautions after primary THA using the posterolateral approach would not increase the short-term (less than three months) risk of dislocation. . Patients and Methods. We prospectively monitored a group of unselected patients undergoing primary THA managed with standard precautions (n = 109, median age 68.9 years; interquartile range (IQR) 61.2 to 77.3) and a group who were managed with fewer precautions (n = 108, median age 67.2 years; IQR 59.8 to 73.2). There were no significant differences between the groups in relation to predisposing risk factors. The diameter of the femoral head ranged from 28 mm to 36 mm; meticulous soft-tissue repair was undertaken in all patients. The medical records were reviewed and all patients were contacted three months post-operatively to confirm whether they had experienced a dislocation. . Results. There were no dislocations in the less restricted group and one in the more restricted group (p = 0.32). . Conclusion. For experienced surgeons using the posterolateral approach at THA and femoral heads of diameter ≥ 28 mm, it appears safe to manage patients in the immediate post-operative period with minimal precautions to protect against dislocation. Larger studies with adequate statistical power are needed to verify this conclusion. Take home message: Experienced orthopaedic surgeons using the posterolateral approach for THA should not fear an increased dislocation rate if they manage their patients with a minimal precautions protocol. Cite this article: Bone Joint J 2016;98-B:589–94

Dual mobility cups (DMC) reduce the risk of dislocation in femoral neck fractures (FNF). Direct anterior approach (DAA), historically promoted for better stability, has been developed in recent years for better functional results. The aim of this study was to compare the early functional results of DMC in FNF by DAA versus posterolateral approach (PLA). A prospective study was conducted on a continuous series of patients who received DMC for FNF by DAA or PLA. The primary endpoint was Harris Hip Score and Parker score assessed at the first follow-up visit. Intraoperative complications were collected during hospitalization. One year clinical results and all cause revision rate were also collected. Radiographic data of cup positioning and limb length were evaluated. Fifty-two patients were included in the DAA group and 54 in the PLA group. Two patients were lost to follow-up. The mean age was 72.8 years. There was no significant difference in HHS or Parker score at 3 and 12 months follow up (p=0.6, p= 0.75). DAA was associated with more intraoperative complications with 4 fractures and 1 femoral nerve deficit (p=0.018). There were 3 revisions in the DAA group (1 infection, 1 dislocation, 1 peri prosthetic fracture) and 1 in the PLA group (infection), which was not statistically significant (p=0.34). Cup anteversion was 6° greater and inclination 9° lesser in DAA group (p=0.028, p<0.01). Results suggest that DAA does not provide any early functional benefit in THA-DMC for FNF compared to PLA. It could lead to more intraoperative complications and a higher revision rate. DAA requires an experienced surgeon and careful patient selection

Aims. The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). Methods. This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. Results. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). Conclusion. While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J 2021;103-B(3):500–506

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Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length.

We determined the effect of the surgical approach on perfusion of the femoral head during hip resurfacing arthroplasty by measuring the concentration of cefuroxime in bone samples from the femoral head. A total of 20 operations were performed through either a transgluteal or an extended posterolateral approach. The concentration of cefuroxime in bone was significantly greater when using the transgluteal approach (mean 15.7 mg/kg; 95% confidence interval 12.3 to 19.1) compared with that using the posterolateral approach (mean 5.6 mg/kg; 95% confidence interval 3.5 to 7.8; p < 0.001). In one patient, who had the operation through a posterolateral approach, cefuroxime was undetectable. Using cefuroxime as an indirect measure of blood flow, the posterolateral approach was found to be associated with a significant reduction in the blood supply to the femoral head during resurfacing arthroplasty compared with the transgluteal approach

Aims. It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively. Methods. Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis. Results. The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon’s age) was not a significant factor. Conclusion. Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826–832

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy. 55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used. As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible. Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time

Dislocation is one of the most common complications after revision THA using the posterolateral approach. Although the cause of dislocation after revision THA is multifactorial, the historically high dislocation rates have been shown to be significantly reduced by closing the posterior capsule and by the use of large diameter (36 and 40 mm) femoral heads. The relative importance of each of these strategies on the rate of dislocation remains unknown. We undertook a study to determine if increasing femoral head diameter, in addition to posterior capsule closure would influence the dislocation rate following revision THA. We retrospectively reviewed 144 patients who underwent a revision THA. We included all patients who underwent revision THA with closure of the posterior capsule and who had at least a 2-year minimum follow-up. We excluded patients undergoing a revision THA for dislocation or multistage revision for infection since these patients would likely have deficient posterior tissues. Forty-eight patients had a 28 mm femoral head, 47 had a 32 mm head and 49 patients had a 36 mm femoral head. At a minimum follow-up of 2 years, there were 3 dislocations. There were no dislocations in the 28 mm group (0%), 2 in the 32 mm group (4%) and 1 in the 36 mm group (2%). All patients were successfully treated with a closed reduction. No patients had recurrent dislocation. Head size alone was not found to significantly decrease the risk of dislocation (28mm vs 32mm p=0.12; 28mm vs 36mm p=0.27; 32mm vs 36mm p=0.40). Both large diameter heads and careful attention to surgical technique with posterior capsule closure can decrease the historically high dislocation rate after revision THA when utilizing the posterolateral approach. The additional use of a large diameter head did not have a significant impact on the already low dislocation rate. Capsular closure outweighs the effect of femoral head diameter in preventing dislocation following revision THA through a posterolateral approach

Aims. Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint. Methods. For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for Cutibacterium. Results. A total of 23 out of 404 cultures (collected from 101 patients) were positive for a microorganism, with a total of 22 patients having a positive culture (22%). Overall, 15 of the cultures in 14 patients were positive for Cutibacterium sp. (65%), of which Cutibacterium acnes comprised the majority (n = 13; 87%). Other isolated microorganisms include coagulase-negative Staphylococcus (n = 6), Clostridium (n = 1), and Corynebacterium (n = 1). Of all positive cultures, 15 were obtained from the anterior location (65%), of which seven (60%) were from the most proximal biopsy location. However, these findings were not statistically significant (anterior vs lateral, p = 0.076; proximal vs distal, p =0.238). Conclusion. Approximately 14% (14/101) of the patients demonstrated a positive Cutibacterium colonization about the hip, the majority anteriorly. Given the high colonization rate of Cutibacterium, alternative skin preparations for total hip arthroplasty should be considered. Cite this article: Bone Joint J 2020;102-B(7 Supple B):52–56

Introduction. Post-operative gait abnormalities are recognized following total hip arthroplasty (THA). Despite global improvement in functional outcome, gait abnormality persists for a decade or more. In this study 3-dimensional gait analysis (3DGA) was performed using a portable system with Inertial Measurement Units (IMUs) to quantify this abnormality. Methods. The gait of 55 patients with monarthrodial hip arthrosis was measured pre-operatively and at one year post-surgery. Patients with medical co-morbidity or other conditions affecting their gait were excluded. Six IMUs were aligned at the level of the anterior superior iliac spines, mid-thigh and mid-leg. Data was analysed using proprietary software. Each patient underwent a conventional THA using a posterolateral approach. 92 healthy individuals were assessed for comparison. Results. Pre-operative movement in the sagittal plane of the ipsilateral hip (mean range 20.4) and the contra-lateral non-diseased hip (35.3 degrees) was reduced compared to the control group (40.5 degrees), (P<0.001). The pre-operative movement of both knees was reduced compared with normal (P<0.001). Pelvic movement on the ipsilateral side was increased. After one year ipsilateral hip movement significantly improved (Mean range 28.9 deg SD 6.6) but did not reach normal values (P<0.001). Movement measured in the contralateral hip was further reduced with a mean difference of −5.25 degrees (95% CI −8.06 to −2.43). Knee movement on both sides increased but not to normal values (p<0.001). There was increased coronal movement bilaterally at the thigh and calf one year after surgery. Discussion and Conclusion. Gait after routine THA does not return to normal. Unilateral hip pathology causes bilateral gait abnormality affecting the entire kinematic chain. This portable technology allows practical assessment of gait in the outpatient setting and will enable identification of key aspects of gait abnormality to target during rehabilitation following THA

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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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The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA).

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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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The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA).

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Several short- and mid-term studies have shown minimal liner wear of highly cross-linked polyethylene (HXLPE) in total hip arthroplasty (THA), but the safety of using thinner HXLPE liners to maximize femoral head size remains uncertain. The objective of this study was to analyze clinical survival and radiological wear rates of patients with HXLPE liners, a 36 mm femoral head, and a small acetabular component with a minimum of ten years’ follow-up.

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The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.

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Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS).

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The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate.

We present the mid- to long-term results of the Chiari pelvic osteotomy for dysplastic hips. We followed 135 hips in 129 patients, with a mean age at the time of surgery of 24 years, for a mean of 16.2 years. We used the anterior iliofemoral approach without trochanteric osteotomy in the initial 31 hips. Thereafter, we used transtrochanteric approaches in an attempt to ensure that the osteotomy was at the most appropriate level, and to advance the high-riding greater trochanter distally. The next 79 hips therefore underwent a posterolateral approach and the most recent 25 hips an Ollier lateral U approach. The clinical result was excellent or good in 103 hips (77%). The outcome in 104 hips in which we used a transtrochanteric approach was superior, the osteotomy level was more appropriate and a Trendelenburg gait less common than in 31 hips in which we used an anterior approach. We therefore recommend the use of a transtrochanteric approach in order to ensure that the osteotomy is at an appropriate level and in order to achieve effective distal advancement of the high-riding greater trochanter