The study of spinopelvic anatomy and movement has received great interest as these characteristics influence the biomechanical behavior (and outcome) following hip arthroplasty. However, to-date there is little knowledge of what “normal” is and how this varies with age. This study aims to determine how dynamic spino-pelvic characteristics change with age, with well-functioning hips and assess how these changes are influenced by the presence of hip arthritis. This is an IRB-approved, cross-sectional, cohort study; 100 volunteers (asymptomatic hips, Oxford-Hip-sore>45) [age:53 ± 17 (24-87) years-old; 51% female; BMI: 28 ± 5] and 200 patients with end-stage hip arthritis [age:56 ± 19 (16-89) years-old; 55% female; BMI:28 ± 5] were studied. All participants underwent lateral spino-pelvic radiographs in the standing and deep-seated positions to determine maximum hip and spine flexion. Parameters measured included lumbar-lordosis (LL), pelvic incidence, pelvic-tilt (PT), pelvic-femoral angles (PFA). Lumbar flexion (ΔLL), hip flexion (ΔPFA) and pelvic movement (ΔPT) were calculated. The prevalence of spinopelvic imbalance (PI–LL>10?) was determined. There were no differences in any of the spino-pelvic characteristics or movements between sexes. With advancing age, standing LL reduced and standing PT increased (no differences between groups). With advancing age, both hip (4%/decade) and lumbar (8%/decade) flexion reduced (p<0.001) (no difference between groups). ΔLL did not correlate with ΔPFA (rho=0.1). Hip arthritis was associated with a significantly reduced hip flexion (82 ±;22? vs. 90 ± 17?; p=0.003) and pelvic movements (1 ± 16? vs. 8 ± 16?; p=0.002) at all ages and increased prevalence of spinopelvic imbalance (OR:2.6; 95%CI: 1.2-5.7). With aging, the lumbar spine loses its lumbar lordosis and flexion to a greater extent that then the hip and resultantly, the hip's relative contribution to the overall sagittal movement increases. With hip arthritis, the reduced hip flexion and the necessary compensatory increased pelvic movement is a likely contributor to the development of hip-spine syndrome and of spino-pelvic imbalance

Background. Online video is increasingly becoming a key source for people to satisfy their information needs. YouTube is one of the post popular websites used for information exchange, with more than one billion unique visitors every month. Questions/purposes. In an attempt to participate in personal health decisions related to hip arthritis, patients may access YouTube for further information. As YouTube is a non peer-reviewed platform and little is known about the quality of available videos. We therefore asked the following research questions: (1) What is the information quality of YouTube videos related to the diagnosis of hip arthritis and (2) what information for the treatment of hip arthritis can be found on YouTube?. Methods. YouTube search was performed on December 23, 2014 for videos related to the diagnosis and the treatment of hip arthritis. The following search terms were used: (1) hip arthritis, (2) hip arthritis symptoms, (3) hip arthritis diagnosis, (4) hip arthritis treatment and (5) hip replacement. After exclusion of videos that did not meet the inclusion criteria, 133 videos were analyzed. In order to qualitatively assess the YouTube video content for to the diagnosis and the treatment of hip arthritis, two new grading systems with a scale of 0 to 12 points were developed. Videos were grouped into poor quality (grade 0–3), moderate quality (grade 4–7) and excellent quality (grade 8–12), respectively. Videos were categorized into the following: educational-physician, educational- non physician, commercial, technique, personal testimony or other. Results. The vast majority of YouTube videos lack essential information for an appropriate diagnosis of hip arthritis. Eighty-four percent (n=112) were graded as being of poor quality, 14 percent (n=19) of moderate quality and only 2 percent (n=2) of excellent quality, respectively. The information quality of educational-physician videos for the diagnosis of hip arthritis was significantly higher (p < 0.001) than for educational-non physician videos. YouTube is a poor information source for the treatment of hip arthritis. In 86 percent (n=114), videos provided poor information quality. Eleven percent (n=15) of videos had a moderate quality and only 3 percent (n=4) an excellent quality, respectively. The quality of information for the treatment of hip arthritis was significantly higher (p = 0.005) than the quality of information for the diagnosis of hip arthritis. Conclusions. The present review of YouTube video material demonstrates that hip arthritis diagnosis and treatment information is overall insufficient. The exchange of video-based information is going to grow rapidly within the next years and videos going to become the primary source of information. The medical community should take chance of the opportunity the define gold standards for comprehensive and innovative evidence-based educational videos addressing the diagnosis and treatment of hip arthritis

INTRODUCTION. In total hip arthroplasty, preoperative planning is almost indispensable. Moreover, 3-dimensional preoperative planning became popular recently. Anteversion management is one of the most important factors in preoperative planning to prevent dislocation and to obtain better function. In arthritic hip patients osteophytes are often seen on both femoral head and acetabulum. Especially on femoral head, osteophytes are often seen at posterior side and its surface creates smooth round contour that assumes new joint surface. (Fig. 1). We can imagine new femoral head center tracing that new joint surface. OBJECTIVES. In the present study, the posterior osteophytes are compared in osteoarthritic patients and other patients. MATERIALS & METHODS. Anteversion and new anteversion which was reduced by osteophyte formation were assessed in 28 hip CAT scans, (22 arthritic hips, 6 avascular necrotic hips). RESULTS. Only in arthritic patients, osteophytes on posterior side were observed. The anteversion was 33.7+/− 13.0 degree in arthritic patients, which was reduce to 29.7+/−13.1 degree. The mean difference was 4.0+/−4.7 degree reduction. In AVN patients the mean anteversion was 21.4 +/− 9.40 in AVN patients. No reduction was observed in AVN patients. DISCUSSION. Osteophytes are often created to make the biomechanical situation better. This phenomenon is possiblly explained that those posterior osteophytes have been formed for proper reduction of excessive anteversion

Introduction. We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm. Materials and methods. A retrospective study of 19 patients who presented with dual pathology was performed and the patients were assessed with regards to pre and post-operative symptoms, walking distance, and neurological status. Results. There were 17 patients with improvement in the spinal stenotic symptoms following hip replacement to an extent that none required spinal surgery. There were two patients who had spinal surgery after THR, at varying lengths following hip replacements as their spinal stenotic symptoms worsened over time, and had lateral spinal stenosis on MRI. Discussion. In advanced hip osteoarthritis, a fixed flexion deformity may develop at the hip leading to an exaggerated lumbar lordosis in erect posture. In the presence of co-existing spinal stenosis, the exaggerated lumbar lordosis may worsen the spinal stenotic symptoms while standing and walking. Cadaveric & Radiological studies have shown that canal narrowing occurs with increased lordosis/ extension in the lumbar spine. Our findings suggest that when central lumbar spinal stenosis coexists with bilateral hip arthritis and FFD at the hip, THR should be offered first. Successful hip surgery for arthritis correcting significant fixed flexion deformity would lessen the lumbar lordosis, thus correcting the excessive pathological narrowing. If a patient is fit enough, simultaneous bilateral THR via an anterior type of approach makes surgical correction of FFD easier. Although it has been suggested in the literature that patients with spinal stenosis have a increased risk of neurological impairment following THR, we did not find any clear association

Introduction

Interactions between hip, pelvis and spine, as abnormal spinopelvic movements, have been associated with inferior outcomes following total hip arthroplasty (THA). Changes in pelvis position lead to a mutual change in functional cup orientation, with both pelvic tilt and rotation having a significant effect on version. Hip osteoarthritis (OA) patients have shown reduced hip kinematics which may place increased demands on the pelvis and the spine.

Sagittal and coronal planes assessments are commonly done as these can be adequately studied with anteroposterior and lateral radiographs. However, abnormal pelvis rotation is likely to compromise the outcome as they have a detrimental effect on cup orientation and increased impingement risk. This study aims to determine the association between dynamic motion and radiographic sagittal assessments; and examine the association between axial and sagittal spinal and pelvic kinematics between hip OA patients and healthy controls (CTRL).

A femoral head/neck ratio (HNR) of less than 1.27 is associated with an increased risk of arthritis. The aim of this study was to establish whether there is evolutionary evidence that the homonin, bipedal stance has led to alterations in HNR that predispose humans to osteoarthritis (OA).

Specimens provided by The Natural History Museums of London, Oxford and the Department of Zoology, University of Oxford were grouped according to gait pattern, HAKF (Hip and knee flexed), Arboreal (ability to stand with hip and knee joints extended) and homonin/bi-pedal. Specimens included those from Devonion, Triassic, Jurrasic, Cretaceous, Miocene, Paleolithic, Pleistocene periods to modern day. Three-dimensional skeletal geometries were segmented using CT images and HNR measurements were taken from coronal views. These were compared with the HNR of 119 asymptomatic human volunteers and 210 patients that had a hip joint replacement for primary OA.

Species of the HAKF group had the smallest HNR (1.10, SD:0.09). Species of the Arboreal group had significantly higher HNR (1.63, SD:0.15) in comparison to the Bipedal group (1.41, SD:0.04) (p=0.006), Human (1.33, SD:0.08) and the OA group (1.3, SD:0.09).

The range of movement associated with arboreal habitat caused an associated change in HNR. This study would suggest that the HNR peaked in the Miocene period with species that ambulated on both ground and trees. More recent homonin gait appears to have developed a smaller HNR and humans have the smallest amongst their close ancestors. Evolutionary theory would suggest that modern environmental pressures might pre-dispose future hominin evolution to OA, secondary to a further reduction in HNR.

Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to knee arthritis but could not tolerate a total knee arthroplasty due to poor quadriceps control. A custom osteointegration prosthesis was inserted with a view to converting to the proximal segment to a total hip replacement if required. The patient went on to develop ipsilateral symptomatic hip arthritis but altered acetabular anatomy required a custom tri-flange component (Ossis, Christchurch, New Zealand) and a custom proximal femoral component to link with the existing osseointegration component (Osseointegration Group of Australia, Sydney, Australia) were designed and implanted. The 18 month follow up of the custom hip components showed that the patient had Oxford hip scores that were markedly improved from pre-operatively. Knee joint heights were successfully restored to equal when the patient's prosthesis was attached. The patient describes feeling like “a normal person”, walks unaided for short distances and can ambulate longer distances with crutches. Advances in design and manufacture of implants have empowered surgeons to offer life improving treatments to patients with challenging anatomy. Using a custom acetabular tri-flange and osseointegration components is one possible solution to address symptomatic ipsilateral hip and knee arthropathy in the context of PFFD in adulthood

Aim. Decubitus ulcers are found in approximately 4.7% of hospitalized patients, with a higher prevalence (up to 30%) among those with spinal cord injuries. These ulcers are often associated with hip septic arthritis and/or osteomyelitis involving the femur. Girdlestone resection arthroplasty is a surgical technique used to remove affected proximal femur and acetabular tissues, resulting in a substantial defect. The vastus lateralis flap has been employed as an effective option for managing this dead space. The aim of this study was to evaluate the long-term outcomes of this procedure in a consecutive series of patients. Method. A retrospective single-center study was conducted from October 2012 to December 2022, involving 7 patients with spinal cord injuries affected by chronic severe septic hip arthritis and/or femoral head septic necrosis as a consequence of decubitus ulcers over trochanter area. All patients underwent treatment using a multidisciplinary approach by the same surgical team (orthopedic and plastic surgeons) along with infectious disease specialists. The treatment consisted of a one-stage procedure combining Girdlestone resection arthroplasty with unilateral vastus lateralis flap reconstruction, alongside targeted antibiotic therapy. Complications and postoperative outcomes were assessed and recorded. The mean follow-up period was 8 years (range 2-12). Results. Of the 7 patients, 5 were male and 2 were female, with a mean age of 50.3 years at the time of surgery. Minor wound dehiscence occurred in 28.6% of the flap sites, and 2 patients required additional revisional procedures—one for hematoma and the other for bleeding. There were no instances of flap failure, and complete wound healing was achieved in an average of 32 days (range 20-41), with the ability to load over the hip area. No cases of infection recurrence or relapse were observed. Conclusions. An aggressive surgical approach is strongly recommended for managing chronic hip septic arthritis or proximal femur osteomyelitis in patients with spinal cord injuries. A single-stage procedure combining Girdlestone resection arthroplasty with immediate vastus lateralis muscle flap reconstruction proves to be an effective strategy for dead space management and localized antibiotic delivery through the vastus muscle, giving reliable soft tissue coverage around the proximal femur to avoid the recurrence of pressure ulcers. The implementation of a standardized multidisciplinary protocol contributes significantly to the success of reconstruction efforts

Introduction. Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TFOI and also had THR, performed at least two years prior. Six patients had TFOI then THR, one simultaneous, one THR then TFOI. All constructs were in continuity from hip to prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in subjective hip pain, K-level, daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but one patient did not have complete mobility and quality of life survey data at both time periods. Results. Four (50%) were male, average age 52.7±14.8 years. Three patients (38%) had amputation for trauma, three for osteosarcoma, one each (13%) infected total knee and persistent infection after deformity surgery. One patient died one year after THR+TOFA from subsequently diagnosed pancreatic cancer. One patient had superficial debridement for infection with implant retention after five years. No implants were removed, no fractures occurred. All patients reported severe hip pain preoperatively versus full relief of hip pain afterwards. K-level improved from 0/8=0% K>2 (six were wheelchair-bound) to 5/8=63% (p=.026). At least 8 hours of prosthesis wear was reported by 2/7=29% before TOFA vs 5/7=71% after (p=.286). The QTFA improved in all categories, but not significantly: Global (40.0±21.6 vs 60.0±10.9, p=.136), Problem (50.2±33.2 vs 15.4±8.4, p=.079), and Mobility (35.9±26.8 vs 58.3±30.7, p=.150). The SF36 also improved minimally and not significantly: Mental (53.6±12.0 vs 54.7±4.6, p=.849) and Physical (32.5±10.9 vs 36.3±11.2, p=.634). Conclusions. THR+TFOI is a successful reconstruction option for amputees who desire relief from severe pain related to hip joint degeneration, and also the opportunity for improved mobility and quality of life that TFOI typically confers. In our cohort, the procedure proved safe: no associated deaths, no removals, one soft tissue debridement. Mobility improved markedly. Quality of life improved, but not to significant thresholds as measured by the surveys. THR+TFOI appears safe and reasonable to offer to transfemoral amputees with painful hip joint degeneration

The success of total hip replacement (THR) is closely linked to the positioning of the acetabular component. Malalignment increases rates of dislocation, impingement, acetabular migration, pelvic osteolysis, leg length discrepancy and polyethylene wear. Many surgeons orientate the cup in the same anteversion and inclination as the inherent anatomy of the acetabulum. The transverse acetabular ligament and acetabular rim can be used as a reference points for orientating the cup this way. Low rates of dislocation have been reported using this technique. Detailed understanding of the anatomy and orientation of the acetabulum in arthritic hips is therefore very important. The aim of this study was to describe the anteversion and inclination of the inherent acetabulum in arthritic hips and to identify the number that fall out with the ‘safe zone’ of acetabular position described by Lewinnek et al. (anteversion 15°±10°; inclination 40°±10°). A series of 65 hips, all with symptomatic osteoarthritis undergoing THR were investigated. Patients with developmental dysplastia of hip (DDH) were excluded. All patients had a navigated THR as part of their normal clinical treatment. A posterior approach to the hip was used. A commercially available non image based computer navigation system (Orthopilot BBraun Aesculap, Tuttlingen, Germany) was used. Rigid bodies (using active trackers) were attached to pelvis and femur. Anterior pelvic plane was registered using the two anterior superior iliac spines and pubic symphysis. The femoral head dislocated and removed and the labrum and soft tissue were excised to clear floor and rim of the acetabulum. Inner size of the empty acetabulum was sized with cup trials and appropriately size trial fixed with a computer tracker was then aligned in the orientation of the natural acetabulum as defined by the acetabular rim ignoring any osteophytes. The inclination and anteversion were calculated by the software. Surgery then proceeded with guidance of the computer navigation system. The computer software defines the anatomical values of orientation, to allow comparison with radiographs these were converted to radiological values as described by Murray et al. The acetabular inclination in all hips was also measured on pre-operative anteroposterior pelvic radiographs. This was done using digital radiographs analysed with the PACS system (Kodak, Carestream PACS Client, version 10.0). Acetabular inclination was measured using as the angle between a line passing through the superior and inferior rim of the acetabulum and a line parallel to the pelvis as identified by the tear drops, using the method described by Atkinson et al. All patients were Caucasian and had primary osteoarthritis. There were 29 males and 36 females. The average age was 68 years (SD 8). Mean anteversion was 9.3° (SD 10.3°). Anteversion for males was significantly lower than females with a mean difference of −5.5° (95%CI −10.5°,−0.5°) p = 0.033 but there was no significant difference in the number falling outside the “safe zone”. Mean inclination was 50.4° (SD 7.4°). There was no significant difference between males and females with respect to inclination angle or the number that fell outside the “safe zone”. Overall 69% of patients had a combined inclination and anteversion of the native acetabulum that fell outside the “safe zone” of Lewinnek. Mean acetabular inclination falls out with the ‘safe zone’. This trend has been seen in a recent study of arthritic hips using CT scans which found that the average angle of inclination in both males and females was greater than the upper limit of the safe zone. This study using CT also demonstrated a statistically significant 5.5° difference between males and females in terms of anteversion. This is the same as the figure we have found in our work. Inherent acetabular orientation in arthritic hips falls out with the safe zone defined by Lewinnek in 69% of cases. When using the natural acetabular orientation as a guide for positioning implants it should therefore not be assumed this will fall with in the safe zone although the validity of safe zones itself is questionable. Variation between patients must be taken into account and the difference between males and females, particularly in terms of anteversion, should also be considered

INTRODUCTION. Childhood diseases involving the proximal femoral epiphysis often cause abnormalities that can lead to end-stage arthritis at a relatively young age and the need for total hip arthroplasty (THA). The young age of these patients makes hip resurfacing arthroplasty (HRA) an alternative and favorable option due to the ability to preserve femoral bone. Patients presenting with end-stage hip arthritis as sequelae of childhood diseases such as Legg-Calves-Perthes (LCP) and slipped capital femoral epiphysis (SCFE) pose altered femoral anatomy, making HRA more technically complicated. LCP patients can result in coxa magna, coxa plana and coxa breva causing altered femoral head-to-neck ratio. There can also be acetabular dysplasia along with the proximal femoral abnormalities. SCFE patients have altered femoral head alignment. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. Additionally, many of these patients have retained hardware, making resurfacing more complicated. We report findings of a cohort of patients, with history of either LCP or SCPE who underwent HRA to treat end-stage arthritis. METHODS. Data was retrospectively collected for patients who had HRA for hip arthritis as a result of either LCP (n=67) or SCFE (n=21) between 2004 and 2014 performed by two surgeons. Demographic information, clinical examination and improvement was collected pre and postoperatively. Improvement was determined using Harris Hip Scores (HHS) and UCLA activity scores. Anteroposterior radiographs were measured pre and postoperatively to determine leg length discrepancy. Radiographs were inspected postoperatively for radiolucent lines, implant loosening and osteolysis. Kaplan-Meier survivorship for freedom from reoperation for any reason was calculated. Paired student t-tests were used to compare groups. RESULTS. The average age at the time of surgery was 44 years (11.8–68), with an average follow-up of 3.7 years (.22–11.2). Retained hardware was present in a total of 5 patients, 1 LCP and 4 SCFE. Preoperative HHS was 58.3 (33–83), which increased significantly to 94.9 (55–100) at the most recent postoperative timepoint (p<.0001). The most recent UCLA activity score was 7 (1–10). Average leg length discrepancy preoperatively was 7.5mm (0–20), which significantly improved to 0.6mm (0–7.5) postoperatively (p<.0001). At most recent follow-up, metal ion testing revealed median chromium level of 2.3 parts per billion (ppb, 1–7.7) and median cobalt level of 1.5 (0–9.2). There were three failures in the group with 1 LCP due to instability at 2.7 years, and 2 SCFE due to femoral neck fracture at 1 month in one and clinical failure due to unexplained pain at 5.5 years in one. Revision surgery was done in 2 patients, 1 LCP and 1 SCFE. Radiographic examination of all non-failure HRA patients revealed implants to be in good alignment with no indication of implant loosening at the most recent postoperative timepoint. Kaplan-Meier survivorship for freedom from revision was 96.2 at 5 years. CONCLUSION. The findings demonstrated increase in functional outcomes in patients who underwent HRA for osteoarthritis associated with LCP and SCFE. There was no increase in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure

Introduction. The success of total hip replacement (THR) is closely linked to the positioning of the acetabular component. Malalignment increases rates of dislocation, impingement, acetabular migration, pelvic osteolysis, leg length discrepancy and polyethylene wear. Many surgeons orientate the cup to inherent anatomy of the acetabulum. Detailed understanding of the anatomy and orientation of the acetabulum in arthritic hips is therefore very important. The aim of this study was to describe the anteversion and inclination of the inherent acetabulum in arthritic hips and to identify the number that fall out with the ‘safe zone’ of acetabular position described by Lewinnek et al. (anteversion 15°±10°; inclination 40°±10°). Materials and Methods. A series of 65 hips all with symptomatic osteoarthritis undergoing THR were investigated. Patients with dysplastic hips were excluded. All patients had a navigated THR as part of their normal clinical treatment. A commercially available non image based computer navigation system (Orthopilot BBraun Aesculap, Tuttlingen, Germany) was used. Anterior pelvic plane was registered using the two anterior superior iliac spines and pubic symphysis. Inner size of the empty acetabulum was sized with cup trials and appropriately size trial fixed with a computer tracker was then aligned in the orientation of the natural acetabulum as defined by the acetabular rim ignoring any osteophytes. The inclination and anteversion were calculated by the software. The acetabular inclination in all hips was also measured on pre-operative anteroposterior pelvic digital radiographs. Acetabular inclination was measured using as the angle between a line passing through the superior and inferior rim of the acetabulum and a line parallel to the pelvis as identified by the tear drops, using the method described by Atkinson et al. Results. All patients were Caucasian and had primary osteoarthritis. There were 29 males and 36 females. The average age was 68 years (SD 8). The inclination was 50.4(SD 7.4) and 58.8(SD 5.7) on navigation and radiographs respectively. The anteversion was 9.3(SD 10.3) on navigation. Anteversion for males was significantly lower than females with a mean difference of −5.5° (95% CI −10.5°, −0.5°) with a p value of 0.033. There was no significant difference with respect to inclination. Overall 69% of patients had a combined inclination and anteversion of the native acetabulum that fell outside the “safe zone” of Lewinnek. Conclusions. Inherent acetabular orientation in arthritic hips falls out with the safe zone defined by Lewinnek in 69% of cases. When using the natural acetabular orientation as a guide for positioning implants it should therefore not be assumed this will fall with in the safe zone although the validity of safe zones itself is questionable. Variation between patients must be taken into account. The difference between males and females, particularly in terms of anteversion, should also be considered

Over the past decade there has been a shift in the approach to management of many femoral neck fractures. As noted by Miller et al. those trends are reflected in the practice patterns of surgeons applying for board certification through the American Board of Orthopaedic Surgeons. From 1999 to 2011 there was a trend toward total hip arthroplasty and corresponding small decreases in the use of hemi-arthroplasty and internal fixation for treatment of femoral neck fractures. For many years the treatment approach has been a simple diagnosis-related algorithm predicated upon classification of the fracture as displaced (historically treated with hemi-arthroplasty) or non-displaced (historically treated with internal fixation). More recently, however, the focus has shifted to a patient-centered approach. In the patient-centered approach factors such as age, functional demands, pre-existent hip disease and bone quality should all be considered. In the contemporary setting it is still important to distinguish between displaced and non-displaced fracture patterns. Non-displaced femoral neck fractures, regardless of patient age or activity, are well-suited to closed reduction and internal fixation, most commonly with three cannulated screws. The union rate is high in non-displaced fractures treated with internal fixation and the benefits of preserving the native hip joint are substantial. Displaced femoral neck fractures in younger active patients, particularly those without pre-existent hip arthritis, are best treated with early anatomic reduction and internal fixation. While a subgroup of young, active patients who undergo ORIF may fail, the benefits of native hip preservation in that group are again substantial. Displaced femoral neck fractures in older patients or those with substantial pre-existing hip arthritis are best treated with arthroplasty. The biggest practice change has been the trend to total hip arthroplasty as opposed to hemi-arthroplasty for a subgroup of patients. Total hip arthroplasty is now favored in almost all active, cognitively well-functioning patients as the degree of pain relief is better and the risk of reoperation is lower in the current era (32mm and 36mm femoral heads). Hemi-arthroplasty, either uni-polar or bi-polar, remains an appropriate treatment for cognitively impaired patients who also have limited functional demands in whom the risk of dislocation is particularly high

Introduction. Success of total hip replacement (THR) is closely linked to positioning of the acetabular component. Malalignment increases complication rates. Our aim was to describe the anteversion and inclination of the inherent acetabulum in arthritic hips and identify the number that fall out with the ‘safe zone’ of acetabular position described by Lewinnek et al. (anteversion 15±10 degrees; inclination 40±10 degrees). Materials/Methods. A series of 65 hips undergoing non-image based computer navigated THR for Osteoarthritis were investigated. Anteversion and inclination was measured with the help of cup trials fixed with computer trackers aligned in orientation of the natural acetabulum. The acetabular inclination in all hips was measured on pre-operative digital radiographs. Results. There were 29 males and 36 females with average age of 68 years. Anteversion of males was significantly lower than females with a mean difference of −5.5 degrees (95% CI-10.5–0.5 degrees) with p value of 0.033. There was no significant difference with respect to inclination. Overall 69 % of patients had a combined inclination and anteversion that fell outside the ‘safe zone’. Conclusion. Mean acetabular inclination falls outwith the ‘safe zone’ but mean anteversion falls within. The inherent acetabular anatomy of arthritic hips varies widely. Females have significantly more anteversion. Care should be taken when using inherent anatomy of acetabulum as a guide when doing a THR

Aims. Accurate positioning of the acetabular component is essential for achieving the best outcome in total hip arthroplasty (THA). However, the acetabular shape and anatomy in severe hip dysplasia (Crowe type IV hips) is different from that of arthritic hips. Positioning the acetabular component in the acetabulum of Crowe IV hips may be surgically challenging, and the usual surgical landmarks may be absent or difficult to identify. We analyzed the acetabular morphology of Crowe type IV hips using CT data to identify a landmark for the ideal placement of the centre of the acetabular component as assessed by morphometric geometrical analysis and its reliability. Patients and Methods. A total of 52 Crowe IV and 50 normal hips undergoing total hip arthroplasty were retrospectively identified. In this CT-based simulation study, the acetabular component was positioned at the true acetabulum with a radiographic inclination of 40° and anteversion of 20° (Figure 1). Acetabular shape and the position of the centre of the acetabular component were analyzed by morphometric geometrical analysis using the generalized Procrustes analysis (Figure 2). To describe major trends in shape variations within the sample, we performed a principal component analysis of partial warp variables (Figure 3). Results. The plot of the landmarks showed that the centre of the acetabular component of normal hips was positioned around the centre of the acetabulum and superior and slightly posterior on the acetabular fossa (Figure 3). The acetabular shapes of Crowe IV hips were distinctively triangular; the ideal position of the centre of the acetabular component was superior on the posterior bony wall (Figure 3). The first and second relative warps explained 34.2% and 18.4% of the variance, respectively, compared with that of 28.6% and 18.0% in normal hips. We defined the landmark as one-third the distance from top on the posterior bony wall in Crowe IV hips. The average distance from the centre of the acetabular component was 5.6 mm. There were 24 hips (50%) for which the distance from 1/3 pbw was within 5 mm, and 43 hips (89.6%) for which the distance was within 10 mm. Conclusions. Morphometric geometrical analysis showed that the acetabulum shape of Crowe type IV hips was distinctively triangular; the centre of the acetabular component was not positioned at the centre of the acetabulum, but rather superior on the posterior bony wall. The point one-third from the top on the posterior bony wall was a useful landmark for surgeons to set the acetabular component in the precise position in Crowe IV hips. This avoids the risk of using a smaller acetabular component and destruction of the anterior wall. For any figures or tables, please contact the authors directly

The childhood hip conditions of Developmental Dysplasia, Legg-Calve-Perthes Disease and Slipped Capital Femoral Epiphysis have a wide spectrum of anatomical outcomes following childhood treatment; ranging from morphologies, which result in normal hip function throughout life, to severely deranged morphologies, which result in pain and disability during childhood and adolescence. Some of these outcomes are as a result of well-intentioned interventions that result in catastrophic complications. In 2003, after years of working with impingement complicating periacetabular osteotomies and building on the work of William Harris, Reinhold Ganz published his concepts of ‘cam’ and ‘pincer’ hip impingement, and how these anatomical morphologies resulted in hip arthritis in adulthood. These concepts of impingement were added to his previous published work on hip instability to provide a comprehensive theory describing how hip arthritis develops on the basis of anatomical abnormalities. Surgical techniques have been developed to address each of these morphological pathologies. Ganz's concepts of hip impingement and instability may be applied to severe paediatric hip deformities to direct reconstructive joint preserving surgery to both the femur and the acetabulum. Ganz's surgical approaches have also been refined for use in paediatric hip surgery to allow radical reshaping salvage osteotomies to be performed on the developing femoral head with minimal risk of the devastating consequence of vascular Necrosis

The majority of patients who develop hip arthritis have a mechanical abnormality of the joint. The structural abnormalities range from instability (DDH) to impingement. Impingement leads to osteoarthritis by chronic damage to the acetabular labrum and adjacent cartilage. In situations of end-stage secondary DJD, hip arthroplasty is the most reliable treatment choice. In young patients with viable articular cartilage, joint salvage is indicated. Treatment should be directed at resolving the structural abnormalities that create the impingement. Femoral abnormalities corrected by osteotomy or increased head-neck offset by chondro-osteoplasty creating a satisfactory head-neck offset. This can safely be done via anterior surgical dislocation. The acetabular-labral lesions can be debrided and/or repaired. Acetabular abnormalities should be corrected by “reverse” PAO in those with acetabular retroversion or anterior acetabular debridement in those with satisfactory posterior coverage and a damaged anterior rim. Often combinations of the above are indicated

BACKGROUND. The obesity crisis in the United States has caused a significant increase of hip arthritis. Surgical complication rates are higher in this population and guidelines are being used to select patients who are acceptable candidates for surgical intervention. This retrospective study evaluated the complication rates for obese patients undergoing total hip replacement compared to non-obese patients as defined by the World Health Organization (WHO). Additionally, we compared complication rates of the direct anterior approach (ATHA) versus the posterior approach (PTHA) in a consecutive group of patients using similar protocols. METHODS. This study is an IRB approved retrospective review of 210 patients undergoing ATHA and 201 patients undergoing PTHA during the same time period by 2 experienced, high-volume total joint surgeons. Non-obese patients were compared to obese patients using WHO body mass index (BMI) classification. Minor and major complications were reviewed as well as surgical time, length of stay, disposition, and short-term outcome measures (including pain scores, narcotic use, and assistive device use). RESULTS. The non-obese cohort (BMI < 30) had lower complication rates (2.8% major, 4.4% minor) when compared to the obese cohort (8.7% major, 9.9% minor). Major complications by obese class were as follows: Class I 8.6%, Class II 7.1% and Class III 11.5%. The non-obese ATHA cohort had lower complication rates (0.8% major, 5.0% minor) compared to the PTHA cohort (5.0% major, 6.7% minor). ATHA obese patients had 6.3% major and 9.9% minor complication rates, compared to 11.1% major and 10.0% minor complication rates in PTHA. Lastly, the evaluation of short term outcomes showed more favorable results for ATHA compared to PTHA for both obese and non-obese patients. CONCLUSION. Obesity was associated with an increased risk of complications and less favorable short-term outcomes following THA. Direct anterior THA was also associated with lower complication rates and more favorable short-term outcomes

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

The elements of my routine pre-operative planning include skin and scar assessment, the limb length (physical exam and radiographic assessments), the socket type, the stem type, and radiographic templating. Blood management is rarely an issue for primary total hips today and I generally do not recommend pre-operative autologous donation. I currently use a low molecular weight heparin for venous thromboembolic prophylaxis for most all patients. All of my patients have pre-operative medical clearance from a hospital intensivist. A press-fit modular cementless socket is my “workhorse”, although I occasionally use supplemental fixation with spikes (low bone density) or screws (shallow or otherwise deficient hemisphere). Cemented fixation is reserved for hips with radiation necrosis. I use a dual-offset tapered cementless stem in most cases but will use a modular stem in dysplastic, post-traumatic, or severely osteoporotic femurs. I template every case. My goals are to determine component sizes - “the part inside the bone” and improve the biomechanics of the hip – “the part outside the bone”. Sizing is relatively straightforward. For the socket, I use the teardrop and the superior bony edge as landmarks for size and position. I use a Johnson's lateral view radiograph to assess socket version and anterior osteophytes. With a tapered stem, proximal fit on the AP radiograph is the goal and the stem does not need to be canal filling. For the neck resection, I reference off the lesser trochanter. Medialisation of the hip center of rotation (COR) decreases the moment arm for body weight; increasing the femoral off-set lengthens the lever arm for the abductor muscles. These changes in hip biomechanics have a double benefit: a reduction in required abductor forces and lower joint reaction forces. There is accumulating clinical evidence that such favorable alterations in biomechanics can improve clinical outcomes and reduce wear. Higher femoral offset has been associated with greater hip abduction motion and abductor muscle strength. In two independent studies, higher femoral offset has been associated with a significant reduction in polyethylene wear. The traditional arthroplasty goal has been to re-create the offset of the operated hip. In an analysis of 41 patients with one arthritic hip and one clinically and radiographically normal hip (Rolfe et al., 2006 ORS), we found that the horizontal femoral offset of the arthritic hip was, on average, 6mm less than that of the normal, contralateral hip. Considering this, and with medialisation of the COR, is it reasonable to make the femoral offset a few millimeters greater than that pre-op. With modular trial components, final offset and limb-length adjustments are made intra-operatively by assessing soft tissue tension, joint stability and range of motion. Applying these principles in a consecutive series of 40 hips, the hip center of rotation was medialised by 5.6mm and the horizontal femoral offset was increased by an average of 9.5mm, being larger than the normal, contralateral hip by an average of 5.2mm. This combination increased the net biomechanical advantage (NBA) of the diseased hip to an average of 12.5% more than the normal, contralateral hip. The increase in femoral offset is compensated for by medialising the center of rotation. The average lateralisation of the proximal femur of 3.9mm did not cause trochanteric bursitis or other pain. When the offset is right, soft tissue tension can be maintained without over-lengthening. In this series, 2.9mm average lengthening resulted in the reconstructed limb being an average of 1.1mm shorter than the normal side