Aims. The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults. Methods. A within-trial economic evaluation was conducted based on data collected from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized controlled trial in the UK. Resource use was measured over 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from the NHS and personal social service perspective. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was represented graphically using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that cemented implants were cost-saving (mean cost difference -£961 (95% confidence interval (CI) -£2,292 to £370)) and increased QALYs (mean QALY difference 0.010 (95% CI 0.002 to 0.017)) when compared to uncemented implants. The probability of the cemented implant being cost-effective approximated between 95% and 97% at alternative cost-effectiveness thresholds held by decision-makers, and its net monetary benefit was positive. The findings remained robust against all the pre-planned sensitivity analyses. Conclusion. This study shows that cemented HA is cost-effective compared with hydroxyapatite-coated uncemented HA in older adults with displaced intracapsular hip fractures. Cite this article: Bone Joint J 2022;104-B(8):922–928

Aims. To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults. Methods. Using data from a multicentre randomized controlled trial (World Hip Trauma Evaluation 8 (WHiTE-8)) in the UK, a within-trial economic evaluation was conducted. Resource usage was measured over 120 days post randomization, and cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY), gained from the UK NHS and personal social services (PSS) perspective in the base-case analysis. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. The base-case analysis showed that high-dose, dual-antibiotic cement had a significantly higher mean cost (£224 (95% confidence interval (CI) -408 to 855)) and almost the same QALYs (0.001 (95% CI -0.002 to 0.003)) relative to single-antibiotic cement from the UK NHS and PSS perspective. The probability of the high-dose, dual-antibiotic cement being cost-effective was less than 0.3 at alternative cost-effectiveness thresholds, and its net monetary benefit was negative. This finding remained robust in the sensitivity analyses. Conclusion. This study shows that high-dose, dual-antibiotic cement is unlikely to be cost-effective compared to single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults. Cite this article: Bone Joint J 2023;105-B(10):1070–1077

We report a randomised prospective trial of the early results of three types of treatment for displaced intracapsular hip fractures. We used a questionnaire sent to patients at about six months (Nottingham Health Profile, NHP) in addition to clinical assessments. There was a 67.4% usable response to the questionnaire, similar to that in other studies using the NHP. There were more responders from younger patients, those walking independently before injury and those with higher mental test scores on admission. In the younger group (65 to 79 years) we found a trend for better scores in most NHP indices after the use of a bipolar prosthesis rather than a unipolar prosthesis or internal fixation, particularly for social function, pain and physical mobility. Postal assessment using the NHP gave a satisfactory response rate even in the elderly, and can provide an extra assessment to complement or replace hospital follow-up in some circumstances

Aim

This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar.

Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004).

We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

Introduction. The National Institute for Health and Care Excellence (NICE) currently recommends the use of total hip replacement (THR) for displaced intracapsular hip fractures in cognitively competent patients and who were independently mobile with the maximum use of one stick prior to the injury. Method. We conducted a prospective cross sectional study of the management of hip fractures within a defined geographic region in the North East of England to assess current practice and variation in provision of THR for displaced intracapsular hip fracture. Results. A total of 879 patients with hip fracture, admitted to eight acute trauma units were included in this study. 169 of 462 patients with displaced intracapsular hip fractures fulfilled the NICE criteria for THR. THR was performed for only 49 of the eligible patients (29%). There was significant variation in THR provision between the eight units (0% THR usage to 50% usage) (p<0.001). In the patients with a displaced intracapsular fracture, there were statistically significant differences in the age, ASA grade, AMTS and pre-injury walking ability between patients who underwent fixation, THR or hemiarthroplasty (all p≤0.05). There was an increased chance of undergoing THR if a patient was 77 years (the median age for the THR eligible cohort) or younger compared to older than 77 years (RR=7.9, 95%CI 2.8–22.0, p<0.001) and if the patients were either ASA grade 1 or 2 compared to ASA grade 3 (RR=2.7, 95%CI 1.0–7.3, p=0.06). The reasons given by the treating surgeon for not performing THR in eligible patients were multifactorial. Conclusion. There is significant variation in the provision of THR for eligible hip fracture patients which is influenced by both patient demographics and also by the unit to which the patient is admitted

Background. Total hip arthroplasty (THA) is increasingly used for active patients with displaced intracapsular hip fractures. Dislocation rates in this cohort remain high postoperatively compared to elective practice, yet it remains unclear which patients are most at risk. The aim of this study was to determine the dislocation rate for these patients and to evaluate the contributing patient and surgeon factors. Methods. A five-year retrospective analysis of all patients receiving THA for displaced intracapsular hip fractures from 2013–18 was performed. Data was collected from the institutions' hip fracture database, including data submitted to the National Hip Fracture Database (NHFD). Cox regression analysis and log-rank tests were implemented to evaluate factors associated with THA dislocation. Patient age, sex, ASA grade, surgeon seniority, surgical approach, femoral head diameter and acetabular cup type were all investigated as independent factors. Results. A total of 196 patients, with a mean age of 72 (range 49–90), received THA for hip fracture between 2013–18. A posterior approach, using standard cemented acetabular components and a 28mm femoral head, was used in 133 cases (72%). Fourteen dislocations (7%) were observed during this period, with 5 patients requiring revision surgery. Of these dislocations, all were performed through posterior approaches with standard cemented cups. 28mm femoral heads were used in all cases except one, which used a 32mm femoral head. In Cox regression analysis, ASA grade, but not age or sex, was significantly associated with dislocation (hazard ratio = 4.5; 95% confidence interval 2.0–10.0; p<0.001). On log rank testing no statistically, significant association was found between dislocation and surgeon grade (p=0.85), surgical approach (p=0.31), femoral head size (p=0.85) or cup type (p=0.30). Discussion. This study demonstrates an increased risk of dislocation following THA for hip fracture with higher ASA grades. It may be appropriate to offer more stable implants to this cohort of patients

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Introduction: Despite its common occurrence there is still controversy regarding the choice of treatment for the displaced intracapsular hip fracture in the elderly patient. Aim: To compare internal þxation and hemiar-throplasty in a prospective randomised controlled trial. Method: 455 patients aged over 70 years with a displaced intracapsular hip fracture were randomised to either hemiarthroplasty or internal þxation. Results: Internal þxation has shorter length of anaesthesia (p< 0.0001), lower operative blood loss (p< 0.0001) and lower transfusion requirements (p< 0.0001). Additional surgical procedures were required in 90 patients (39.8%) treated by internal þxation and 12 patients (5.2%) in the arthroplasty group. There was no statistical difference in mortality at one year (p=0.91), however there was a trend to improved survival for the older less mobile patients treated by internal þxation. There was no statistical difference in pain and mobility. Limb shortening was more common after internal þxation (p=0.004). Conclusion: We recommend that displaced intracapsular fractures in the elderly should generally be treated by hemiarthro-plasty, but internal þxation may be appropriate for the frail less mobile patient

Aims. This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures. Patients and Methods. This was a pragmatic, multicentre, multisurgeon, two-arm, parallel group, randomized standard-of-care controlled trial. It was embedded within the WHiTE Comprehensive Cohort Study. The sample size was 964 patients. The setting was five National Health Service Trauma Hospitals in England. A total of 964 patients over 60 years of age who required hemiarthroplasty of the hip between February 2015 and March 2016 were included. A standardized measure of health outcome, the EuroQol (EQ-5D-5L) questionnaire, was carried out on admission and at four months following the operation. Results. Of the 964 patients enrolled, 482 died or were lost to follow-up (50%). No significant differences were noted in EQ-5D between groups, with a mean difference at four months of 0.037 in favour of the Exeter/Unitrax implant (95% confidence interval (CI) 0.014 to 0.087, p = 0.156), rising to 0.045 (95% CI 0.007 to 0.098, p = 0.09) when patients who died were excluded. The minimum clinically important difference for EQ-5D-5L used in this study is 0.08, therefore any benefit between implants is unlikely to be noticeable to the patient. There was no difference in mortality or mobility score. Conclusion. Allowing for the high rate of loss to follow-up, the use of the traditional Thompson hemiarthroplasty in the treatment of the displaced intracapsular hip fracture shows no difference in health outcome when compared with a modern cemented hemiarthroplasty. Cite this article: Bone Joint J 2018;100-B:352–60

Aims: To explore potential predictors of functional outcome one year after the injury in elderly women who sustained a displaced intracapsular hip fracture and who were treated with internal fixation, hemiarthroplasty, or total hip arthroplasty. Methods: Eighty-four women aged > 50 years were enrolled on a consecutive basis in this one-year prospective cohort study reflecting standard day-to-day clinical practice. The main outcome measure was the Rapid Disability Rating Scale version-2 applied at hospital discharge and one year later. Results: The total hip arthroplasty group was younger (p< 0.001) and had a better functional status than the internal fixation or hemiarthroplasty groups (p< 0.001) at hospital discharge. One year later, the best function was still observed in the total arthroplasty group, but the differences were small and failed to achieve the level of statistical significance. During that one-year period, walking ability or mobility did not change significantly after total hip arthroplasty, but a significant proportion of the women developed cognitive impairment, including mental confusion, uncooperativeness, and depression (p< 0.001). Overall, the most significant predictors of poor functional status one year after fracture were increasing age (p=0.005), living in an institution at time of injury (p=0.034), and poor functional status at discharge (p< 0.001). Conclusions: In elderly women with a displaced intra-capsular hip fracture, total hip arthroplasty is associated with a functional benefit within the first months after surgery. However, the extent to which this functional benefit is maintained over time, is less clear. Our results support the need for randomised clinical trials among elderly women with a displaced intracapsular hip fracture to quantify the extent to which the early functional benefit of total hip arthroplasty is maintained in the long run or compromised by progressive cognitive impairment and other negative determinants of functional outcome

Introduction. Total hip arthroplasty (THA) is indicated in independently mobile patients sustaining displaced intracapsular hip fractures. Studies presently suggest that the anterolateral approach is preferable to the posterior approach due to a perceived reduced risk of reoperations and dislocations. However, these observations come from small studies with short follow-up. We assessed whether surgical approach in THA performed for hip fractures effects outcomes. Patients and Methods. A retrospective observational study was performed using data collected prospectively by the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary stemmed THAs implanted for hip fractures between 2003–2015 were eligible for inclusion (n=19,432). The two surgical approach groups (posterior versus anterolateral) were propensity-score matched for multiple potential patient and surgical confounding factors (n=14,536, with 7,268/group). Outcomes (implant survival, patient survival, intraoperative complications) were compared between the approach groups using regression analysis. Results. Five-year implant survival rates were similar between posterior and anterolateral approaches (97.3% vs. 97.4%; sub-hazard ratio (SHR)=1.15 (95% CI 0.93–1.42)). Five-year implant survival rates free from revision for dislocation (SHR=1.28 (CI=0.89–1.84)) and free from revision for periprosthetic fracture (SHR=1.03 (CI=0.68–1.56)) were also comparable. Thirty-day patient survival was significantly higher with a posterior approach (99.5% vs. 98.8%; hazard ratio (HR)=0.44 (CI=0.30–0.64)), which persisted at 1-year (HR=0.73 (CI=0.64–0.84)) and 5-years (HR=0.87 (CI=0.81–0.94)). The posterior approach had a lower risk of intraoperative complications (odds ratio=0.59 (CI=0.45–0.78)). Discussion. This is the largest study assessing the influence of surgical approach on outcomes following THA performed for hip fractures. In THA for hip fractures, the posterior approach had a similar risk of revision, and a lower risk of mortality and intraoperative complications compared with the anterolateral approach. Conclusion. We propose that the posterior approach is safer than the anterolateral approach when performing THA for hip fractures and should be preferred where possible

Evidence suggests as little as 32percnt; of those with a displaced intracapsular hip fracture who meet the NICE eligibility criteria currently undergo a total hip replacement (THR). The reason for this discrepancy is not clear. This study therefore set out to examine the reasons behind this lack of adherence to these guidelines through the use of a questionnaire to current Trauma & Orthopaedic surgery consultants across Scotland. An invitation to take part in the survey was distributed through the Scottish Committee for Orthopaedics & Trauma (SCOT) email address list. A series of 10 questions were designed to determine the background of participants, their experience at performing hip fracture surgery (including THR) and their thoughts regarding its use in the hip fracture setting. Results were collated at the end of the study period and quantitatively analysed where possible. There were 91 responses in total. 53percnt; of individuals said they would offer those meeting the NICE criteria a THR less than 76percnt; of the time. The most commonly used alternative was a cemented bipolar hemiarthroplasty (51percnt;). Hip surgeons were more likely to perform or supervise THR for hip fracture than non-hip surgeons (p<0.0001). There were a wide variety of reasons why people would not offer a THR including dislocation rate, technical complexity and inadequate evidence for use. Overall this study highlights current trends and barriers in the provision of THR to hip fracture patients. This knowledge can be used to ascertain research priorities to maximise the quality of care in this setting

We performed single-photon-emission CT (SPECT) and planar bone scans to assess femoral head vascularity in ten patients with displaced intracapsular hip fracture. The heads were labelled with tetracycline and after excision at hemiarthroplasty were assessed for tetracycline uptake distribution by fluorescence under UV light. The four which had the greatest tetracycline uptake were normal on SPECT and planar imaging. In two cases the planar bone scans were normal although SPECT suggested avascularity thus giving false-negative results. Surgeons should be aware of this; SPECT may prove to be a more accurate method of assessing vascularity of the femoral head in fractures of the femoral neck

The admission radiographs for 404 patients with a displaced intracapsular hip fracture treated by reduction and internal fixation were classified using five different variables. These were the Garden grade, a modified Garden grading, a ratio of fracture displacement, direct measurement of fracture shortening and trochanteric shortening. Inter-observer reliability of the various classifications was also studied. Only trochanteric shortening had an acceptable degree of inter-observer variation. For the Garden grading equal numbers of grade III and IV fracture healed. For the modified Garden grading 36% of Grade III fractures developed non-union against 48% of grade IV fractures (p value =0.02). The ratio method and fracture shortening were related to fracture healing complications, but trochanteric shortening was predictive of fracture healing (15.2 mms versus 11.0 mm), although the usefulness of this measure in clinical practice has to be questioned

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility. The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group. In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended

Introduction. Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties. Method. Cohort study of displaced intracapsular hip fractures treated with hemiarthroplasty between 1999–2009 at one institute. A total of 3094 hemiarthroplasties performed; out of which 1002(32.4%) were cemented and 2092(67.6%) were uncemented. 48hour and 30day mortality rates for the two groups were compared and a multivariate Cox regression model used to eliminate confounding factors. Significant confounding factor included age, sex, mini mental test score, medical co-morbidities, Nottingham Hip Fracture Score and delay to surgery. Results. The study showed that, after eliminating confounding factors, 48hour mortality in the cemented group was 0.3% compared to 0.5% in the uncemented group (p=0.388). However, the adjusted 30day mortality rate for the cemented group (4%) was shown to be significantly lower than for the uncemented group (10.8%) (p< 0.001). Conclusion. The use of cement in hip hemiarthroplasty is not associated with an increased rate of mortality at 48hours or at 30days. Along with emerging evidence of better post-op recovery and patient satisfaction with the use of a cemented prosthesis, we support the use of cement for all patients undergoing hip hemiarthroplasty

Background. There is increasing interest in the use of Total Hip Replacement (THR) for reconstruction in patients who have suffered displaced intracapsular hip fractures. Patient selection is important for good outcomes but criteria have only recently been clearly defined in the form of national guidelines. This study aims to investigate patient reported outcomes and satisfaction after Total Hip Replacement (THR) undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis in order to assess the safety and effectiveness of national clinical guidelines. Methods. 100 patients were selected for treatment of displaced hip fractures using THR between 1 January 2007 and 31 December 2009. These patients were selected using national guidelines and were matched for age and gender with 300 patients who underwent contemporaneous THR as an elective procedure for osteoarthritis. Results. Patients undergoing THR for both fracture and as an elective procedure reported excellent outcomes and satisfaction. Hip fracture patients had better post-operative Oxford hip scores (p< 0.001) and SF-12 physical component scores (p< 0.001). Mental component scores were poorer for hip fracture patients (p< 0.001). In this series, the rates of major complications for hip fracture patients were higher than for elective patients. Nevertheless, the rates of dislocation, deep infection and early revision surgery were similar to those widely reported in the literature and considered within acceptable limits after elective surgery. Conclusions. For selected patients, THR undertaken for displaced fractures of the hip produces outcomes which are at least equivalent to those achieved after elective surgery. Selection is critical to this success and the extended use of current guidelines is appropriate and safe

Introduction: Two of commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. Methods: To determine if any difference in outcome exists between these implants, we undertook a prospective randomised controlled trial of 400 patients with a displaced intracapsular hip fracture. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility. Results: The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups. Pain scores were less for those treated by a cemented prosthesis (p value < 0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay, implant related complications, re-operations or post-operative medical complications between the two groups. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group. Discussion: In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to the uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended

Exeter Trauma Stem (ETS) is one of the most common implants used for treating displaced intracapsular hip fractures in the UK. We previously performed a radiographic audit of these implants which showed good placement was difficult. This was in particular relation to leg length discrepancy (LLD). This study reviewed the clinical outcomes of these patients, in particular looking at the relation of leg length discrepancy to outcome. We performed a clinical review of patients at 3 months and 1 year post ETS for hip fracture. Oxford hip score (OHS), Trendelenberg test, Visual Analogue Score (VAS) and walking aids required were recorded. Leg length discrepancy was determined radiographically on initial post op X-ray. This was recorded as Even (+/− 5mm), 6-10mm Long and >10mm long. Seventy-two patients were reviewed at 3 months and 21 at 1 year. Mean VAS was 1.6. At 3 months 66% were Trendelenberg positive. Of those Trendelenberg positive at 3 months only 42% remained positive at 1 year. Mean OHS at 3months and 1 year was 30.8 and 32.1 respectively. On radiographic review 38 implants were Even, 24 were 6-10mm Long and 10 implants were >10mm Long. There was no correlation between leg length discrepancy and either VAS or Trendelenberg test. 45 patients ambulated independently pre-op. Of these only 8 ambulated independently post-op, 18 used a stick and 11 a Zimmer frame. There was no correlation between post operative leg length discrepancy and either Visual Analogue Score, OHS or Trendelenberg test. Mean pain score was very low. There was however almost 10% of patients with a VAS greater than 6. 80% of patients dropped one ambulatory level post-op, this is consistent with previous studies. The ETS provides good pain relief with a low complication rate in the vast majority of patients