Introduction. Gluteus medius is disrupted during lateral approach total hip arthroplasty (THA) which may impact its function and ability to control the pelvis. The objective was to compare gluteus medius activation and joint mechanics associated with a Trendelenburg sign (pelvic drop, trunk lean) during gait and hip abductor strength between patients that underwent lateral or posterior THA approaches one year post-surgery and healthy adults. Methods. Participants that underwent primary THA for hip osteoarthritis using lateral (n=21) or posterior (n=21) approaches, and healthy adults (n=21) were recruited for this cross-sectional study. Participants completed five walking trials. Surface electromyography captured gluteus medius activation. A 3-dimensional optical motion capture system measured frontal plane pelvic obliquity and lateral trunk lean angles. Participants performed maximum voluntary isometric contractions (MVIC) on a dynamometer to measure hip abductor torque. Characteristics from gait waveforms were identified using principal component analysis, and participant waveforms were scored against these characteristics to produce principal component scores. One-way analysis of variance and effect sizes (d) compared gait principal component scores and isometric hip abductor torque between groups. Results. Lateral THA group had statistically significant higher gluteus medius PC-scores indicating higher overall amplitudes during gait (p<0.01, d=0.97) and prolonged midstance activation (p=0.01, d=0.95) compared to the healthy group (Figure). There were no statistically significant (p>0.05) differences in pelvis or trunk angles. Isometric hip abductor torque was significantly (p=0.03, d=0.74) lower in the lateral THA than healthy group. There were no statistically significant differences between THA groups (d=0.27–0.50). Conclusions. Although the lateral THA group had lower abductor torque, there were no Trendelenburg signs during gait. Elevated gluteus medius activation in this group was a compensation for the weakness, and the muscle produced sufficient force to control the pelvis. Also, 1 year post-THA there were no statistically significant gait differences between lateral and posterior approaches. For any tables or figures, please contact the authors directly

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system

The management of periprosthetic joint infection is challenging and the duration of systemic antibiotic therapy whether it be during the interval phase or after reimplantation of a new prosthesis is controversial. We report our experience of managing chronic periprosthetic infection of the hip by the two stage exchange procedure.

Patients who were scheduled to undergo a two stage revision for chronic periprosthetic infection of the hip were identified from our prospective database.

Of 425 patients with microbiologically proven periprosthetic infection, 369 (87%) underwent a two stage procedure, leaving 56 patients who did not proceed to reimplantation. 41 of these were clinically infection free but for personal or medical reasons did not proceed. The remaining 15 had persistent infection. The mean age at the time of the first stage was 68 years (26 – 92 yrs). 256 (61%) patients were alive for review. The mean time between stages was 6.3 months with a mean follow up after the second stage was 65 months (range 5 to 276 months).

The success rate of a single 1^st stage debridement, confirmed by negative cultures at the time of second stage reimplantation was 94%. 19 patients underwent a repeat 1^st stage debridement and were classed as failures of the 1^st stage. At the time of final review, 340 (92%) patients were deemed infection free out of those who had completed a 2 stage exchange.

The duration of systemic antibiotic treatment after both the 1^st and 2^nd stages was divided into <48 hrs and >48 hours. There was no significant difference in the success of the 1^st stage procedure in patients who received < 48 hours (48% of the patients) as opposed to > 48 hours (p = 0.98, Chi Squared Test, Relative Risk 1.009). Similarly there was no difference in the overall success of the two stage procedure irrespective of the duration of antibiotic therapy with 76% of patients receiving <48hrs of antibiotics after the second stage.

Aggressive surgical debridement together with targeted local and short term systemic antibiotic therapy should be the mainstay of treatment in two stage revision surgery.

Aims. The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol. Methods. The study involved a retrospective review of our prospectively collected database from which we identified all patients who underwent an intended two-stage revision for PJI of the hip. All patients had a diagnosis of PJI according to the major criteria of the Musculoskeletal Infection Society (MSIS) 2013, a minimum five-year follow-up, and were assessed using the MSIS working group outcome-reporting tool. The outcomes were grouped into ‘successful’ or ‘unsuccessful’. Results. A total of 299 two-stage revision THAs in 289 patients met the inclusion criteria, of whom 258 (86%) proceeded to second-stage surgery. Their mean age was 68.1 years (28 to 92). The median follow-up was 10.7 years (interquartile range (IQR) 6.3 to 15.0). A 91% success rate was seen in those patients who underwent reimplantation, decreasing to 86% when including those who did not proceed to reimplantation. The median duration of postoperative systemic antibiotics following the first stage was five days (IQR 5 to 9). There was no significant difference in outcome between those patients who were treated with antibiotics for ≤ 48 hours (p = 0.961) or ≤ five days (p = 0.376) compared with those who were treated with longer courses. Greater success rates were seen for Gram-positive PJIs (87%) than for Gram-negative (84%) and mixed-Gram PJIs (72%; p = 0.098). Conclusion. Aggressive surgical debridement with a high local concentration of targeted antibiotics at the time of first-stage revision surgery for PJI of the hip, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship, and reduced hospital costs. Cite this article: Bone Joint J 2023;105-B(5):511–517

Background. Postoperative recovery after routine total hip arthroplasty (THA) can lead to the development of prolonged opioid use but there are few tools for predicting this adverse outcome. The purpose of this study was to develop machine learning algorithms for preoperative prediction of prolonged post-operative opioid use after THA. Methods. A retrospective review of electronic health records was conducted at two academic medical centers and three community hospitals to identify adult patients who underwent THA for osteoarthritis between January 1. st. , 2000 and August 1. st. , 2018. Prolonged postoperative opioid prescriptions were defined as continuous opioid prescriptions after surgery to at least 90 days after surgery. Five machine learning algorithms were developed to predict this outcome and were assessed by discrimination, calibration, and decision curve analysis. Results. Overall, 5507 patients underwent THA, of which 345 (6.3%) had prolonged postoperative opioid prescriptions. The factors determined for prediction of prolonged postoperative opioid prescriptions were: age, duration of pre-operative opioid exposure, preoperative hemoglobin, and certain preoperative medications (anti-depressants, benzodiazepines, non-steroidal anti-inflammatory drugs, and beta-2-agonists). The elastic-net penalized logistic regression model achieved the best performance across discrimination (c-statistic = 0.77), calibration, and decision curve analysis. This model was incorporated into a digital application able to provide both predictions and explanations; available here: . https://sorg-apps.shinyapps.io/thaopioid/. Conclusion. If externally validated in independent populations, the algorithms developed in this study could improve preoperative screening and support for THA patients at high-risk for prolonged postoperative opioid use. Early identification and intervention in high-risk cases may mitigate the long-term adverse consequence of opioid dependence. For any tables or figures, please contact the authors directly

Elevated synovial leukocyte count is a minor criterion derived from the musculoskeletal infection society (MSIS) widely used in clinical practice for diagnosis of prosthetic joint infection. There is evidence to suggest analysis within 1 hour, preferentially within 30 minutes, of aspiration reduces the risk of ex vivo cell lysis occurring during prolonged transport. Multiple site working is more common practice and the availability of a lab on site to perform these tests is not always possible. We aimed to assess whether we could safely perform synovial leukocyte counts within our cold site in the diagnosis of prosthetic joint infection. We reviewed all orthopaedic synovial fluid aspirates within the lower limb arthroplasty unit from April 2021 – April 2022 performed at South Tees NHS Foundation Trust. We assessed time from aspirate to the lab using electronic data resources. This information was compared with the labs ability to perform a synovial leukocyte count to determine the impact of delays on testing. 110 patients (34.5% hips and 63.6% knees) were identified between two sites. Time from aspirate to lab ranged from 0 mins to 26 hrs 34 mins. Mean time to processing was 3hrs 10 mins. 50% of all samples had a synovial leukocyte count performed. 67% of patients had a cell differential performed. There was no difference in the ability to perform a synovial leukocyte count between samples process in < 2hours vs > 6 hours. We conclude that it is safe practice to perform joint aspirates for the work up of periprosthetic joint infections in sites where no laboratory is immediately available as the delay to processing synovial fluid does not alter the ability to perform a synovial leukocyte count. This study will provide evidence to enable the work up of periprosthetic joint infections in cold centres and therefore reduce the delay in diagnosis and proceeding management

Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF). This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel. Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA. This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique

The postoperative pain after hip arthroscopy remains a major challenge in the immediate postoperative period. Adequate postoperative analgesia has been associated with increased patient satisfaction and decreased consumption of opioids. We evaluated the efficacy of pericapsular nerve group block (PENG) versus fascia iliaca block (FIB) in reducing post-operative pain and analgesic consumption within the first 24 hours following arthroscopic management of femoroacetabular impingement (FAI). Thirty-nine patients (17 females and 25 males, ages 18–42 years, mean ± SD (27.9 ± 6.2), and mean BMI of 25.13±5.08 kg/m2 were scheduled for primary arthroscopic management of FAI. Included patients were randomized into two groups according to the block used in each. Group (A) 19 patients were included and had FIB and group (B) 20 patients were included and received PENG block. The efficacy of both techniques was clinically and statistically valuated using VAS score and quadriceps muscle power. There was a statically significance difference in the mean at rest between the two groups at all measured time points following surgery (6, 12, 18 and 24 h). Also, in dynamic pain scores (with hip flexion) scores were statistically significant at 24 hours post-operative (P = .001). Total opioid consumption in the first 24 hours postoperative was lower in the PENG group with significant difference of mean 16.5 ±9.9 mg for PENG group versus 27.5±9.6 mg for FIB group (P < .005). Five patients (26.31%) in FIB group had weaker quadriceps muscle power while none in PENG group patients had quadriceps weakness. PENG block might be considered as an ideal regional anesthesia modality for hip arthroscopy. As an alternative to more conventional regional nerve blocks such as a fascia iliaca block. PENG block is easily performed in the preoperative setting, and appears to spare motor function while providing a prolonged sensory pain relief

Superior team performance in surgery leads to fewer technical errors, reduced mortality, and improved patient outcomes. Scrub nurses are a pivotal part of this team, however they have very little structured training, leading to high levels of stress, low confidence, inefficiency, and potential for harm. Immersive virtual reality (iVR) simulation has demonstrated excellent efficacy in training surgeons. We tested the efficacy of an iVR curriculum for training scrub nurses in performing their role in an anterior approach total hip arthroplasty (AA-THA). Sixty nursing students were included in this study and randomised in a 1:1 ratio to learning the scrub nurse role for an AA-THA using either conventional training or iVR. The training was derived through expert consensus with senior surgeons, scrub nurses and industry reps. Conventional training consisted of a 1-hour seminar and 2 hours of e-learning where participants were taught the equipment and sequence of steps. The iVR training involved 3 separate hour-long sessions where participants performed the scrub nurse role with an avatar surgeon in a virtual operation. The primary outcome was their performance in a physical world practical objective assessment with real equipment. Data were confirmed parametric using the Shapiro-Wilk test and means compared using the independent samples student's t-test. 53 participants successfully completed the study (26 iVR, 27 conventional) with a mean age of 31±9 years. There were no significant differences in baseline characteristics or baseline knowledge test scores between the two groups (p>0.05). The iVR group significantly outperformed the conventionally trained group in the real-world assessment, scoring 66.9±17.9% vs 41.3±16.7%, p<0.0001. iVR is an easily accessible, low cost training modality which could be integrated into scrub nursing curricula to address the current shortfall in training. Prolonged operating times are strongly associated with an increased risk of developing serious complications. By upskilling scrub nurses, operations may proceed more efficiently which in turn may improve patient safety

Given the prolonged waits for hip arthroplasty seen across the U.K. it is important that we optimise priority systems to account for potential disparities in patient circumstances and impact. We set out to achieve this through a two-stage approach. This included a Delphi-study of patient and surgeon preferences to determine what should be considered when determining patient priority, followed by a Discrete Choice Experiment (DCE) to decide relative weighting of included attributes. The study was conducted according to the published protocol ([. https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071. ](. https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071. )). The Delphi study was performed online over 3 rounds with anonymous ranking and feedback. Included factors were voted as either Consensus in, Consensus out, or No Consensus• following an established scoring criterion. A final consensus meeting determined the prioritisation factors (and their levels) to be included in the DCE. The DCE was then conducted using an online platform, with surgeons performing 18 choice sets regarding which merited greater priority between two hypothetical patients. Results were collated and analysed using multinomial logit regression analysis (MNL). For the Delphi study there were 43 responses in the first round, with a subsequent 91% participation rate. Final consensus inclusion was achieved for Pain; Mobility/Function; Activities of Daily Living; Inability to Work/Care; Length of Time Waited; Radiological Severity and Mental Wellbeing. 70 individuals subsequently contributed to the DCE, with radiological severity being the most significant factor (Coefficient 2.27 \[SD 0.31\], p<0.001), followed by pain (Coefficient 1.08 \[SD 0.13\], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 \[SD 0.02\], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months. These results present a new method of determining comparative priority for those on primary hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required

Aims. This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

Introduction. Wound complications following revision total hip arthroplasty (THA) are associated with an increased risk of superficial and deep infections. Closed incision negative-pressure therapy (ciNPT) has been reported to decrease this risk. This study's purpose was to assess if ciNPT decreases the rate of wound complications following revision THA versus a conventional, silver-impregnated dressing. Methods. This was a single center, randomized controlled trial of patients undergoing both septic and aseptic revision THA. Patients received either ciNPT or a silver-impregnated dressing (control) for 7 days. Wound complications within 90 days of the procedure were recorded, including: surgical site infection (SSI), periprosthetic joint infection (PJI), prolonged drainage greater than 5 days, erythema requiring antibiotics, and hematoma formation. An a priori power analysis determined 201 patients per cohort were necessary to demonstrate a 10% decrease in wound complication rate. Results. Between 2017 and 2020, 113 patients have been enrolled: 57 (50.4%) to ciNPT and 56 (49.6%) to the control dressing. Two revisions (1.8%) were performed via a direct lateral approach; all others via a posterior approach. There were no differences in age, BMI, ASA score, revision performed, wound closure method (staples, superficial nylons, subcuticular), or postoperative anti-coagulation (p=0.2–0.8). Seven (12.3%) patients in the ciNPT cohort sustained a wound complication versus 4 (7.1%) in the control cohort (p=0.2). There was no difference in type of wound complication sustained (p=0.4). Four (7.0%) patients in the ciNPT cohort underwent re-operation for wound-related complications (2 PJI, 1 SSI, 1 prolonged drainage) versus zero in the control cohort (p=0.04). Conclusion. Prior studies have shown ciNPT to be effective in decreasing the rate of wound complications in total joint arthroplasty. Preliminary results of this randomized trial of revision THA patients do not corroborate these prior reports. Continued enrollment is required to confirm these initial findings

Aims. A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. Patients and Methods. The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (. sd. 11.8) and 29.1 kg/m. 2. (. sd. 6.1), respectively. Data gathered included the age of the patient, BMI, the American Society of Anesthesiologists (ASA) score, estimated blood loss (EBL), length of stay (LOS), operating time, the presence of intra- or postoperative complications, type of complication, and the surgical approach. The approaches used during the study were posterior, anterior, direct lateral, anterolateral, and the northern approach. The complications that were recorded included prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture. Finally, the need for re-operation was recorded. Means were compared using analysis of variance (ANOVA) and Student’s t-tests where appropriate and proportions were compared using the chi-squared test. Results. A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). Conclusion. Overall, THA has a relatively low complication rate. However, the surgical approach plays a role in the incidence of complications. We found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate. Periprosthetic fracture and surgical site infection contributed most to the early complication rates. Cite this article: Bone Joint J 2019;101-B:646–651

The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand across Scotland for arthroplasty services in the future. Understanding the scale of potential change to operative workflow is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm. This future service demand for primary and revision hip arthroplasty across Scotland, and the rest of the U.K., is hitherto unknown. We set out to provide projections of future primary & revision hip arthroplasty out to 2038 utilising historical trend data (2008–2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age & sex group predictions were also performed. All results are presented per 100,000 population at-risk per year (/100k/year). The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 27% increase. Based on a static 3 day length of stay average this would see 4280 additional patient bed days required for primary hip arthroplasty patients per annum. The number of revision hip arthroplasty procedures for all ages is projected to fall from 14/100k/year to 4/100k/year based on historical trend data. This does not however take into account the suspect increase in primary arthroplasty numbers that is likely to influence future revision rates. Anticipated future demand for primary hip arthroplasty will require significant additional resource and funding to prevent deterioration in quality of care and an increase in patient wait times. Demand for revision arthroplasty is set to decrease, likely on account of improved implant materials, technique, and understanding of best practice to minimise complication risk. This doesn't however take into account the impact of the complex interaction between an increasing primary arthroplasty rate and revision risk. Understanding presented projections of changes to arthroplasty demand is key to future service delivery

Introduction. Previous studies have indicated that prolonged surgical time may lead to higher rates of infection following total hip arthroplasty (THA). The purpose of this study was to evaluate the influence of surgical time on 30-day complications following THA and to determine if there was a time interval associated with worse outcomes. Methods. Patients ≥18 years who underwent THA between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complications were ascertained. Multivariable regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for relevant covariables, and to identify independent predictors of operation length. Covariables of interest included age, sex, American Society of Anaesthesiologists (ASA) class, smoking status, functional status, comorbidities, anesthesia type, and Body Mass Index (BMI). Results. A total of 132,043 THA patients (average age 65 ±12 years) were identified from the database. Of these, 2,177 (1.64%) experienced a major complication, and 3,504 (2.64%) experienced a minor complication within 30-days of the initial procedure. Average operation length was 92.0 minutes (range 20 – 240 minutes). Independent predictors of prolonged operation length included overweight/obese BMI, male sex, cancer, dependent functional status, epidural anaesthetic, and ASA class II, III or IV vs. I Alternatively, older age, current smoking, and spinal anaesthetic were associated with shorter surgical durations. Unadjusted rates of both major and minor complications were significantly higher for patients whose operation lengths were ≥ 120 minutes (P>0.001). Specifically, patients whose operations lasted ≥ 120 minutes had higher rates of septic shock, sepsis, pulmonary embolism (PE), deep vein thrombosis (DVT), urinary tract infection (UTI), renal insufficiency, surgical site infection(SSI) and wound disruption. After covariable adjustment, surgical durations of 90–119 minutes increased the risk of minor complications by 1.2 (95%Confidence interval [95%CI] 1.1–1.3), while surgical durations of 120–180 minutes increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.4 (95%CI 1.2 – 1.5), and surgical durations ≥180 minutes increased the risk of major complications by 2.1 (95%CI 1.8 – 2.6), and minor complications by 1.9 (95%CI 1.6 – 2.3). There was no difference in the overall risk of complications for operation times lasting 20 – 39, 40 – 59, or 60 – 89 minutes (P>0.05). In terms of specific complications, operation length ≥90 minutes was determined to be an independent risk factor for deep and superficial incisional SSI, as well as wound disruption, while operation length ≥ 120 minutes was an independent risk factor for sepsis, UTI, and deep, non-incisional SSI and operation length ≥ 180 minutes was an independent risk factor for PE, DVT, and cardiac arrest (p<0.05). Conclusion. These data indicate that prolonged surgical durations may be an independent predictor of major and minor complications following THA. This suggests that quality improvements could be made to improve operating room efficiency and surgical times and therefore postoperative outcomes

Introduction. The obesity epidemic is a growing problem and must be considered with the projected increased demand for total hip arthroplasty (THA). Previous studies have reported increased complication rates after THA in the obese population, which has led to hesitation in offering surgery to this population. Moreover, some insurers are denying coverage for morbidly obese patients. While many consider obesity a “modifiable” risk factor, very few patients with advanced osteoarthritis have successfully lost substantial weight. The experience of centers that utilize systematic preoperative risk stratification tools and standardized postoperative total joint pathways may be underrepresented in prior studies. The aim of this study is to describe one surgeon's experience performing THA in morbidly and super-obese patient populations using an institutional preoperative Risk Stratification Tool (RST) and total joints pathway. Methods. We conducted a retrospective review of patients undergoing primary THA between May 2014 and December 2017 performed by a single surgeon at a tertiary care referral center. All patients were assessed preoperatively using an institutional RST and had a minimum of 90-day postoperative follow up. Patients were stratified by body mass index (BMI, kg/m. 2. ): non-obese (BMI < 30), obese (30–34), severely obese (35–39), morbidly obese (40–44), and super-obese (≥ 45). Primary outcomes were inpatient and 90-day complications. Continuous and binary parameters were analyzed by Kruskal-Wallis and Fisher exact tests. Logistic regression was additionally utilized to evaluate outcomes by BMI cohort. Results. A consecutive series of 368 patients met inclusion criteria across all BMI cohorts. There was significant variation with respect to age (P=0.001), BMI (P<0.001), diabetes (P=0.008), ASA class (P<0.001), and anesthesia type (P=0.003) (Table 1). Variation among BMI cohorts was also identified for several operative and postoperative parameters, including longer operative and in-room time and greater length of stay (P<0.001) (Table 2). Compared to non-obese patients, super-obese patients had 20.1 greater odds of return to OR within 90 days for superficial surgical site infection (SSI) or prolonged round drainage (P=0.008) (Table 3). Notably, morbidly and super-obese patients were not at significantly increased risk for inpatient intensive care unit (ICU) transfer, blood transfusion, 90-day emergency room visit, or 90-day readmission compared to their non-obese counterparts. For patients in whom 1-year follow-up was available, these differences between BMI cohorts remained insignificant. Conclusions. Patients with BMI>40 are more likely than non-obese patients to have increased postoperative rehabilitation needs but are not at increased risk for in-hospital complications. Super-obese patients have greater risk of superficial SSI or prolonged wound drainage than non-obese patients but are not at increased risk for revision or deep infection in any cohort. Use of a preoperative RST may help to mitigate postoperative complications and readmissions previously associated with morbid and super-obesity. We conclude that THA can be safely performed in super-obese patients and therefore care should not be denied to this population. Summary sentence. Total hip arthroplasty (THA) can be safely performed in morbidly and super-obese patients with the use of a preoperative risk stratification tool (RST) and total joints pathway. For any tables or figures, please contact the authors directly

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided

Literature debates whether fluid aspirates for suspected PJI should undergo prolonged incubation for cultures. We looked at sensitivity and specificity of 14-day cultures, compared to 7-days, for aspirates from prosthetic hips and knees. Design and methods. Conducted at a quaternary referral centre for PJIs from Jan 2017 to July 2019. Suspected PJIs who underwent aspiration, incubated 14 days and later surgical intervention with minimum three tissue samples were included. Results. 176 aspirates were included. This is an increased number compared to our historic figures (average 88 Vs 48 pts/yr). 47 patients had fluid and tissue positive (true positive), 20 fluid +ive but tissue -ive (false positive), 98 fluid and tissue -ive (true negative) and 15 fluid negative but tissue +ive (False negative). Thus, sensitivity 76%, specificity 83%, positive predictive value70% and negative predictive value 87%. Of 88 positive aspirates, only 75% were within 7-day cultures. Low virulence organisms as Propionibacterium acnes and coagulase negative staph were grown later. Of 48 with only one tissue sample positive, 38 were culture-negative on aspiration and 6 grew different organisms on aspirate and tissues. Also, as many were cultured later, it suggests contamination. Conclusion. Increased numbers reflect quaternary referral nature of institution and increasing PJI load. Modest drop in sensitivity and specificity of 14-day cultures compared to 7-day(84 and 85% respectively) is due to higher false negatives. Contamination contributes to false-ive as more tissue samples become positive (there were 1076 tissue samples due to multiple sampling Vs 176 aspirates). Higher tissue yield may also be because they are more representative. Effect of antibiotic use between samples cannot be determined. Organism profile suggest14-day culture produces more contaminant growth despite a well-equipped microbiology lab with laminar airflow for subcultures. Caution in interpreting 14-day results in diagnosis of PJI of Hip and Knee is advised

Introduction. Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNF), especially in physiologically younger patients. While elective THA for primary osteoarthritis (OA) has demonstrated low rates of complications and readmissions, the outcomes of THA for FNF are less predictable. Additionally, these THA procedures are equally included in various alternative payment bundles. Therefore, the aim of this study is to assess postoperative complication rates after THA for primary OA compared with FNF. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2008 to 2016 was queried. Patients were identified using the Current Procedural Terminology (CPT) code for THA (27130) and divided into groups by diagnosis; OA in one group and FNF in another. Univariate statistics were performed. T-test compared continuous variables between groups, and Chi-square test compared categorical variables. Multivariate and propensity matched logistic regression analyses were performed to control for risk factors of interest. The primary outcomes for this study were death or serious morbidity (surgical site infection (SSI), infection, respiratory complication, cardiac complication, sepsis, or blood loss anemia requiring postoperative transfusion). Additional secondary outcomes included the incidence of specific complications, total operative time (time from incision to closure), length of hospital stay and proportion of patients that were discharged home. Results. Analyses included 139,635 patients undergoing THA. OA was the indication in 135,013 cases and FNF in 4,622 cases. Unadjusted analysis showed a significantly higher rate of mortality when THA was done for hip fracture (2.1% vs. 0.1%; p<0.001). There was also a significantly increased rate of serious morbidity for hip fracture patients; including cardiac complications (3.5% vs 0.96%; p<0.001), respiratory complications (1.3% vs 0.2%; p<0.001), postop transfusion (23.1% vs 9.36%; p<0.001), sepsis (0.95% vs 0.3%; p<0.001). There was a significantly higher percentage of patients requiring reoperation (4.5% vs 2.0%; p<0.001) and readmission (8.0% vs 3.5%; p<0.001) in the hip fracture group. There was a significantly higher percentage of patients in the hip fracture groups having operative time >90min (16.4% vs 10.1%; p<0.001), length of stay longer than 5 days (53.8% vs 7.5%; p<0.001), and a significantly lower percentage of patients who were discharged home (39.0% vs 78.0%; p<0.001). Propensity score matching resulted in a cohort of 6,968 patients; 3,484 in both the hip fracture and osteoarthritis groups. Mortality within 30 days was 530% higher, and major morbidity was 36% higher among FNF patients. Reoperation was 40% higher, readmission was 36% higher, operative length at the 90th percentile was 74% higher, prolonged length of stay was 838% higher, and discharge to home was 62% lower for the FNF group compared with OA patients. Logistic, reverse stepwise regression model () results were consistent with the propensity-matched analysis. Discussion and Conclusion. This large database study showed a higher risk of postoperative complications including mortality, major morbidity, reoperation, readmission, prolonged operative time, increased length of stay, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. Without risk adjustment, the bundled payment methods that are applied to THA procedures including those performed for FNF are at a disadvantage and likely inadequate to cover the more costly episode of care related to treating hip fracture patients

Aims

Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure.