Severe heterotopic ossification (grade III and IV) after contemporary total hip arthroplasty (THA) requiring excision is very uncommon. We performed a systematic review of the literature, and report a new case series with operative treatment after primary uncemented THA. A systematic review identified papers describing patients who had excision of heterotopic ossification (HO) after contemporary THA, defined as performed after 1988. Concepts of hip arthroplasty, heterotopic ossification, and surgical excision were searched in MEDLINE, Embase, and Scopus, from database inception to November 2022. Inclusion criteria were: articles that included specific patient data on grade of heterotopic ossification, operative procedure, and prophylaxis. Studies were screened for inclusion by two independent reviewers. Extracted data included demographic data, interval from index surgery to excision, clinical results, and complications. One surgeon performed reoperation for ankylosis of primary THA in three patients with severe pain and deformity. Seven case series or case report studies were included. There were 41 patients, with grade III or IV HO, that had excision, and in five patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation, one gastrointestinal complication, and two recurrences. Treatment of the three patients, with wide excision of peri-articular bone, selective exchange of components, and peri-operative irradiation prophylaxis, was successful in improving motion and deformity. There is insufficient data on the treatment of severe symptomatic HO after contemporary THA. Prophylaxis with low-dose irradiation was successful to prevent recurrence. Multicenter studies will be needed to determine the optimum timing and prognosis for treatment

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years). Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted

The aims of this study were to determine the functional impact and financial burden of isolated and recurrent dislocation after total hip arthroplasty (THA). Our secondary goal was to determine whether there was a difference between patients who were treated non-operatively and those who were treated operatively. . We retrospectively reviewed 71 patients who had suffered dislocation of a primary THA. Their mean age was 67 years (41 to 92) and the mean follow-up was 3.8 years (2.1 to 8.2). . Because patients with recurrent dislocation were three times more likely to undergo operative treatment (p < 0.0001), they ultimately had a significantly higher mean Harris Hip Score (HHS) (p = 0.0001), lower mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (p = 0.001) and a higher mean SF-12 score (p < 0.0001) than patients with a single dislocation. Likewise, those who underwent operative treatment had a higher mean HHS (p < 0.0001), lower mean WOMAC score (p < 0.0001) and a higher mean SF-12 score (p < 0.0001) than those who were treated non-operatively. Recurrent dislocation and operative treatment increased costs by 300% (£11 456; p < 0.0001) and 40% (£5217; p < 0.0001), respectively. The operative treatment of recurrent dislocation results in significantly better function than non-operative management. Moreover, the increase in costs for operative treatment is modest compared with that of non-operative measures. Cite this article: Bone Joint J 2015; 97-B:1046–9

Introduction. The Vancouver Classification System presents a systematic approach to classification of periprosthetic fractures of the proximal femur (PFPFs) that has been validated in previous studies. However, with the introduction of tapered fluted stems and cable plates since the introduction of the Vancouver System, the connection between fracture class and the preferred method of treatment is often unclear. The present study was undertaken to identify fracture patterns surrounding contemporary femoral stems and the relationship between the current method of treatment and the Vancouver Class of the periprosthetic fracture. Methods. Three experienced joint surgeons collected plain radiographs (AP and lateral) and CT/MR scans (n=40) from 72 cases of Vancouver A or B periprosthetic fractures performed over the period 2016–2018. We identified the mode of primary stem fixation and the Vancouver grade of the fracture (A, B1, B2 or B3). Two independent investigators examined all imaging studies and the intraoperative records and recorded: (i) and the location and distribution of the fracture surfaces, and (ii) the presence of incomplete cortical fractures that had initiated within the femoral cortex without completing propagation and (iii) the method of operative treatment. These data were analyzed to examine the incidence of fractures within more than one femoral zone and differences in the fracture patterns corresponding to each Vancouver class. Results. One fifth (21%) of fractures were Type A with the remainder consisting predominantly of Type B2 (39%), with approximately equal proportions of Type B1 (22%) and B3 (18%) fractures. In almost half of Type B2 fractures (a loose femoral stem and a fracture adjacent to the prosthesis), fractures were also present within the metaphysis (ie. Type A+B). In the presence of a cementless femoral stem, fractures often occurred adjacent to the uncoated surface of the stem distal to the proximal ingrowth surface. Type B2 and B3 femurs had similar fracture patterns and degrees of comminution, though their method of treatment differed significantly. Incomplete fractures were identified in every Vancouver class (entire sample: 22%), especially in association with loose stems in poor quality bone (Type B3; 38% of cases). Conclusions. Approximately two-thirds of periprosthetic femoral fractures involve a loose femoral component (ie Types B2 and B3), though bone quality impacts operative treatment. In cementless stems, Vancouver Type B fractures often occur in the unbonded diaphysis between the distal edge of the ingrowth surface and immediately below the stem tip. Incomplete fractures are present in a surprising proportion of cases, suggesting that careful examination of imaging studies is needed to prevent fracture propagation due to inadequate fixation. CT scans are a useful adjunct to supplement plain radiographs. For any tables or figures, please contact the authors directly

Background. There remains a paucity of clinical studies on the effects of coronavirus on perioperative outcomes, with no existing trials reporting on risk factors associated with increased risk of postoperative mortality in these patients. The objectives of this study were to assess perioperative complications and identify risk factors for increased mortality in patients with coronavirus undergoing surgery. Methods. This multicentre cohort study included 340 coronavirus negative patients versus 82 coronavirus positive patients undergoing surgical treatment for neck of femur fractures across nine NHS hospitals within Greater London, United Kingdom. Predefined study outcomes relating to patient demographics, fracture configuration, operative treatment, perioperative complications and mortality were recorded by observers using a standardised data collection proforma. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Findings. Coronavirus positive patients had increased risk of postoperative complications (89.0% vs 35.0%, p<0.001), higher rates of admission to high dependency and intensive care units (61.0% vs 18.2%, p<0.001), and increased length of hospital stay (13.8 ± 4.6 days vs 6.7 ± 2.5 days, p<0.001) compared to coronavirus negative patients. Postoperative complications in coronavirus positive patients included respiratory infections (13.4%), thromboembolic disease (13.4%), acute kidney injury (12.2%), and multi-organ dysfunction (12.2%). Coronavirus positive patients had increased risk of postoperative mortality (30.5% vs 10.3%, p<0.001) compared to coronavirus negative patients, with positive smoking status (Hazard ratio: 15.4 (95% CI: 4.55–52.2, p<0.001) and greater than three comorbidities (Hazard ratio: 13.5 (95% CI: 2.82–66.0, p<0.001) associated with increased risk of mortality. Interpretation. Surgery in coronavirus positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications and increased mortality compared to coronavirus negative patients. Multivariate analysis revealed that smoking and multiple pre-existing comorbidities were associated with increased risk of postoperative mortality

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Aims

To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC).

Aims. To report our experience with trunnion corrosion following metal-on-polyethylene total hip arthroplasty, in particular to report the spectrum of presentation and determine the mean time to presentation. Patients and Methods. We report the presenting symptoms and signs, intraoperative findings, and early results and complications of operative treatment in nine patients with a mean age of 74 years (60 to 86). The onset of symptoms was at a mean of seven years (3 to 18) after index surgery. Results. Patients presented with a variety of symptoms including pain, limp and rash. The preoperative mean serum cobalt level was 7.1 ppb (2.2 to 12.8) and mean serum chromium level was 2.2 ppb (0.5 to 5.2). Metal artifact reduction sequence (MARS) MRI showed fluid collection and possible pseudotumour formation in five hips, fluid collection in two hips, and synovitis/debris in one hip, with no MRI in one patient. Acetabular revision was performed in three patients, six patients underwent liner and head exchange only. The postoperative metal levels decreased in all patients: mean cobalt 0.5 ppb (0 to 1.8) and mean chromium 0.9 ppb (0 to 2.6) at a mean of five months (3 to 8) postoperatively. Seven patients had good pain relief and no complications at one year. There were two major complications requiring reoperation: acute infection at six weeks, for which the patient required two-stage reimplantation; and recurrent dislocation, for which the patient was revised to a dual mobility component. Conclusion. Trunnion corrosion in metal-on-polyethylene THA has a range of presenting symptoms, and may present later than previously described. A high index of suspicion is warranted, and serum cobalt and chromium levels are recommended for diagnosis. Patients should be counselled about possible postoperative complications. Cite this article: Bone Joint J 2018;100-B:898–902

Aims

The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs).

Aims

The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

Aims

The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells.

Trunnion corrosion in metal-on-polyethylene THA is poorly understood, with multifactorial etiology, and the patients present with “hip pain”. We analysed the presenting symptoms and signs, intraoperative findings and the early results and complications of operative treatment. One surgeon treated 9 patients (6 male, 3 female), mean age 74 years, with the onset of symptoms at a mean of 7 years (range 3–18) after index surgery. The taper size was 12/14 in seven, 14/16 in one, and 6 degree in one hip. The preoperative mean cobalt level was 7.1 ppb (range, 2.2–12.8) and mean chromium level was 2.2 ppb (range, 0.5–5.2). MARS MRI showed fluid collection and pseudotumor in 5, fluid collection only in two, and synovitis/debris in one hip. In one patient, there was no preoperative MRI. There were a myriad of clinical presentations: thigh rash alone in one; diffuse leg pain and hip rash in one; acute pseudo-sepsis in one; iliopsoas tendinitis and diffuse rash in one; trochanteric bursitis in one; groin pain only in one; thigh-buttock pain in two; and diffuse hip pain and limp in one patient. Intraoperatively, 6 patients had liner and ceramic (or oxidized zirconium) head exchange only. Three patients had concurrent acetabular revision: one for broken locking mechanism; one because liner was unavailable, and one had acetabular loosening. The postoperative metal levels decreased in all patients: mean cobalt 0.5 ppb (range, 0–1.8) and mean chromium 0.9 ppb (range, 0–2.6). Seven patients had good pain relief and no complications. There were two major complications requiring reoperation: acute infection at 6 weeks and patient required 2-stage reimplantation; and second patient had recurrent dislocation and was revised to a dual mobility component. Trunnion corrosion in metal-on-polyethylene THA has several clinical presentations, including local skin rash, iliopsoas tendinitis, and other limb dysfunction. There should be a high index of suspicion and serum cobalt/chromium levels are recommended for diagnosis. The patients should be counseled about possible postoperative complications

The unparalleled events of the year 2020 continue to evolve and challenge the worldwide community on a daily basis. The COVID-19 pandemic has had a major impact on all aspects of our lives, and has caused major morbidity and mortality around the globe. The impact of COVID-19 on the practice of orthopedic surgery has been substantial with practice shutdowns, elective surgery restrictions, heightened utilization of telemedicine platforms and implementation of precautionary measures for in-person clinic visits. During this transition period the scholarly and educational pursuits of academic surgeons have been de-emphasized as the more immediate demands of clinical practice survivorship have been the priority. This unavoidable focus on clinical practice has heightened the importance of orthopedic subspecialty societies in maintaining an appropriate level of attention on research and educational activities. Under the outstanding presidential leadership of Robert Barrack, MD, The Hip Society adapted to the profound challenges of 2020, and maintained strong leadership in the realms of education and research. The recent 2020 summer meeting of the Hip Society was a testimonial to the resilience and dedication of the Society members to ongoing innovation in research and education. Due to travel and social distancing restrictions the 2020 summer meeting was transitioned from an in-person to a virtual meeting format. Dr Barrack and Program Chair Dr John Clohisy assisted with oversight of the meeting, while Olga Foley and Cynthia Garcia ensured the success of the meeting with remarkable planning and organization. These collaborative efforts resulted in an organized, well-attended, high level scientific meeting with engaging discussion and a remarkable virtual conference environment. The Bone & Joint Journal is very pleased to partner with The Hip Society to publish the proceedings of this very unique virtual meeting. The Hip Society is based in the United States and membership is granted to select individuals for leadership accomplishments in education and research related to hip disease. The Society is focused on the mission of advancing the knowledge and treatment of hip disorders to improve the lives of patients. The vision of the Hip Society is to lead in the discovery and dissemination of knowledge related to disorders of the hip. The annual closed meeting is one of the most important events of the society as this gathering highlights timely, controversial and novel research contributions from the membership. The top research papers from The Hip Society meeting will be published and made available to the wider orthopedic community in The Bone & Joint Journal. This partnership with The Bone & Joint Journal enhances the mission and vision of The Hip Society by international dissemination of the meeting proceedings. Given the far-reaching circulation of The Bone & Joint Journal the highest quality work is available to an expanding body of surgeons, associated healthcare providers and patients. Ultimately, this facilitates the overarching Hip Society goal of improving the lives of our patients. The 2020 virtual Hip Society meeting was characterized by outstanding member attendance, high quality paper presentations and robust discussion sessions. The meeting was held over two days and encompassed 58 open paper presentations divided into ten sessions with moderated discussions after each session. All papers will be presented in this issue in abstract form, while selected full papers passing our rigorous peer review process will be available online and in The Bone & Joint Journal in a dedicated supplement in 2021. The first session of the meeting focused on issues related to complex primary THA and osteonecrosis of the femoral head. Dr Gross presented on the conversion of hip fusion to THA in 28 patents at a mean 7 years. He reported a high clinical success rate, yet complications of heterotopic ossification and neurologic injury were relatively common. Consideration of heterotopic ossification prophylaxis and the selective use of a constrained liner were recommended. Dr Pagnano summarized the use of various contemporary porous acetabular components in 38 hips in the setting of prior pelvic radiation. The mean follow-up was 5 years and 10 year survivorship was 100% with all implants radiographically fixed. Dr Bolognesi's study demonstrated that THA in solid organ transplant patients is associated with higher risk for facility placement, transfusions and readmissions. This patient population also has increased mortality risk (4.3% risk at 1 year) especially lung transplant patients. The second group of papers focused on femoral head osteonecrosis. Dr Iorio presented single center data demonstrating that CT scan was a useful adjunct for diagnosis in the staging work-up for cancer, yet was not useful for ARCO staging and treatment decision-making. On the basic science side, Dr Goodman utilized a rabbit model of steroid-induced femoral head osteonecrosis to determine that immunomodulation with IL-4 has the potential to improve bone healing after core decompression. The session was concluded by Dr Nelson's study of ceramic-on-ceramic THA in 108 osteonecrosis patients. The median 12 year results were outstanding with marked increases in PROs, maintenance of high activity levels, and a 3.7% revision rate. In the second session attention was directed to THA instability and spinopelvic mobility. Dr Sierra presented a machine learning algorithm for THA dislocation risk. Two modifiable variables (anterior/lateral approach, elevated liner) were most influential in minimizing dislocation risk. Dr Taunton's study demonstrated a deep learning artificial intelligence model derived from postoperative radiographs to predict THA dislocation risk. High sensitivity and negative predictive value suggest that this model may be helpful in assessing postoperative dislocation risk. In reviewing a large single-center, multiple surgeon cohort of 2,831 DAA procedures, Dr Moskal noted a very low dislocation rate (0.45%) at minimum 2 years. Importantly, spinopelvic pathology or prior spinal instrumentation was not associated with an increased dislocation risk (0.30%). Dr Huo and colleagues analyzed pelvic tilt during functional gait in patients with acetabular dysplasia. They detected variable pelvic tilt on different surfaces with the data suggesting that patients with more anterior pelvic tilt while standing tend to have greater compensatory posterior pelvic tilt during gait. Dr Lamontagne reported on the sagittal and axial spinomobility in patients with hip OA, and highlighted reductions in pelvic tilt, pelvic-femoral-angle, lumbar lordosis and seated maximal trunk rotation when compared to controls. Dr Dennis showed that differences in spinopelvic mobility may explain the variable accuracy of acetabular version measurements on the cross-table lateral radiographs. Dr Gwo-Chin presented on a comprehensive functional analysis of 1,592 patients undergoing THA and observed that spinopelvic abnormalities are not infrequent (14%) in THA patients. Consistent with these findings Dr Murphy and collaborators identified a low prevalence of previous spinal instrumentation (1.5%), yet a high prevalence of spine stiffness (27.6%) in 149 patients undergoing THA. Session three highlighted various aspects of treating hip disease in young patients. Dr Peters investigated the need for subsequent hip arthroscopy in 272 patients treated with an isolated PAO. Only 4.8% of these patients required subsequent arthroscopy calling into question the routine use of combined arthroscopy and PAO. Three papers addressed questions related to THA in young patients. Dr Berend's study of 2532 hips demonstrated that high activity level was not associated with an increased risk of midterm aseptic or all cause failure. Dr Nunley presented on 43 young patients with an average age of 52 years treated with a cementless stem and modular dual mobility articulation. Stress shielding was minimal and no concerning metal ion release detected. Dr Garvin summarized minimum 15 year data of THA with highly cross-linked polyethylene in patient less than 50 years. These hips performed exceptionally well with no mechanical loosening or radiographic osteolysis. Dr Engh examined 10 year results of the Birmingham Hip Resurfacing implant and reported a 92.9 % overall survivorship, with males less than 55 years achieving a 98.3% survivorship. The session was concluded by long-term data on the Conserve Plus hip resurfacing arthroplasty. Dr Amstutz presented an impressive dataset depicting an 83.1% 20 year survivorship for this early resurfacing cohort. Direct anterior approach total hip arthroplasty was the focus of session four. Dr Meneghini reported on the anesthesia and surgical times of direct anterior and posterior approaches from a large healthcare system database. These data suggested longer OR and surgical times for the DAA both in the inpatient and ASC environments. Dr Clohisy introduced the technique and early outcomes of lateral decubitus position DAA. In a learning curve experience of 257 hips. 96% of acetabular components were in the Lewinneck safe zone, the aseptic revision rate was 0.9% and there were no dislocations. Dr Beaule analyzed femoral stem cement mantle with the DAA and posterior approaches by comparing two matched cohorts. Stem alignment and cement mantle quality were equivalent with both approaches. Similarly, Dr Emerson demonstrated technical feasibility and fewer cemented femoral stem failures when compared to cementless stems in a series of 360 DAAs THAs. The final paper of the session presented by Dr Hamilton examined the impact of surgical approach on dislocation after isolated head and liner exchange. Neither the posterior nor the anterior approach was superior in reducing the dislocation rate for these high dislocation risk procedures. The fifth session explored contemporary topics related to anesthesia and pain management. Dr Byrd opened the session with a comparative study evaluating general versus spinal anesthesia for hip arthroscopy. This preliminary study was provoked by the desire to minimize aerosolized exposure early in the COVID-19 pandemic by transitioning to spinal anesthesia. Both anesthetic methods were effective. Dr Austin presented a randomized, double-blind controlled trial comparing spinal anesthetic with mepivacaine, hyperbaric bupivacaine and isobaric bupivacaine. Mepivacaine patients ambulated earlier and were more likely to be discharged the same day. Dr Mont provided a very timely study on the effects of “cannabis use disorder” and THA outcomes. This administrative database study of 44,154 patients revealed this disorder to be associated with longer hospital stays, increased complications rates and higher costs. Dr Bedair investigated whether a highly porous acetabular component submerged in an analgesic solution could enhance perioperative pain management. Interestingly, this novel strategy was associated with a reduction of postoperative pain scores and opioid consumption in 100 experimental patients compared to 100 controls. The concluding paper of the session by Dr Della Valle examined whether decreased discharge opioids led to increased postoperative opioid refills. A large single-center study of 19,428 patients detected a slight increase (5%) in opioid refills but a reduction in total refill morphine milligram equivalents. The final, sixth session of day one considered various challenging aspects of revision hip arthroplasty. Dr Nam started the session with review of preliminary results from a randomized control trial comparing closed incision negative-pressure therapy with a silver-impregnated dressing for wound management in 113 hips undergoing revision arthroplasty. Unlike previous reports, the negative pressure therapy was associated with a higher reoperation rate for wound-related complications. Dr Bostrom highlighted the potential clinical impact of basic biological interventions by establishing the presence of Neutrophil Extracellular Traps (NETS) in fibrotic tissue from human aseptic loosening specimens and in a murine model of unstable tibial implantation. NET inhibition in the murine model prevented the expected tibial implant osseointegration failure. Dr Lombardi presented early 3.3 year clinical results of a highly porous Ti6al4v acetabular component in complex primary and revision arthroplasty. Survivorship for aseptic loosening was 96.6 % and 95.3% for the primary and revision cases, respectively. Dr Schwarzkopf and colleagues explored the impact of time to revision arthroplasty on clinical outcomes. Analysis of 188 revision cases revealed early revisions (less than 2 years from primary) were associated with worse outcomes, longer hospitalizations and higher reoperation rates. Mid-term results for modular dual mobility implants in revision arthroplasty were reviewed by Dr Lachiewicz who reported on 126 hips at a mean 5.5 years. 11% of hips dislocated and the 6 year survival was 91%. An outer head diameter of 48mm or greater was associated with a lower risk of dislocation. Dr Berry concluded the session by discussing the outcomes of treating the challenging problem of interprosthetic femur fractures. A single-center study of 77 cases treated over 32 years demonstrated a 79% success rate free of reoperation at 2 years with 95% of patients being ambulatory. The second day commenced with the seventh session evaluating recent strategies to improve short-term THA outcomes. Dr Bozic and colleagues investigated the association of quality measure public reporting with hip/knee replacement outcomes. Annual trend data from 2010–2011 and 2016–2017 indicate that hospital-level complication and readmission rates decease after the start of public reporting, yet it is difficult to prove a direct effect. Dr Slover reviewed his institutions experience with the Comprehensive Care for Joint Replacement (CJR) model and emphasized that lower CJR target prices make it increasingly difficult for programs to meet target price thresholds. Cost saving strategies including same day discharge and reduction of home health services may result in smaller losses of positive margins. Dr Barsoum reported on the influence of patient and procedure-related risk factors of length of stay after THA. Patient-related risk factors provided substantial predictive value yet procedure-related risk factors (hospital site and surgical approach) remain the main drivers of predicting length of stay. Dr Hozack reviewed an impressive, single surgeon cohort of 3,977 DAA THAs and analyzed adverse events and 90 day perioperative outcomes. Simultaneous bilateral DAA THA was comparable with unilateral or staged bilateral procedures in regards to complications, readmission rate and home discharge rate but with an increased risk of transfusion. To examine the risk of complications with outpatient joint arthroplasty, Dr Della Valle performed a single-surgeon matched cohort analysis comparing outpatient and inpatient hip and knee arthroplasties. Outpatient procedures were not associated with an increased risk of any postoperative complications and actually experienced fewer emergency department visits. The eighth session covered various contemporary challenges in hip arthroplasty care. Dr Griffin began the session with an analysis of the timing of complications associated with two-stage exchange procedures for periprosthetic joint infection (PJI). Of the 189 hips included, 41.6% had a complication and the mortality was 14.1% at 2.5 years, highlighting the morbidity of this treatment method. Dr Fehring provided data assessing the fate of two-stage reimplantation after failed debridement, antibiotics and implant retention (DAIR) for a prosthetic hip infection. This analysis of 114 hips yielded concerning results demonstrating a 42.9% treatment failure of patients treated with a previous DAIR compared to a 12.3% failure rate in patients treated with an initial 2-stage procedure. Dr Jacobs reviewed the analysis of 106 femoral heads with severe corrosion and identified a chemically dominated etching process termed “column damage” to be a detrimental damage mode within CoCr femoral heads that is directly linked to banding within its microstructure. These data indicate that implant alloy microstructure must be optimized to minimize the release of fretting-corrosion products. Simon Mears presented retrospective data from 184 THAs with a dual modular femoral stem. A subgroup of hips with a modular, cobalt chromium femoral neck had a pseudotumor visualized in 15% with only 55% of these having elevated CoCr levels. These findings may support the use of routine follow-up MARS MRI for modular CoCr femoral neck prostheses. The final two studies explored timely issues related to viral illness and hip surgery. Dr Browne analyzed three large administrative databases to elucidate whether patients are at increased risk for viral illnesses following total joint replacement. The incidence of postoperative influenza after total joint replacement was not increased compared to patients not undergoing total joint replacement surgery suggesting that arthroplasty procedures may not heighten the risk of viral illness. In the final paper of the session Dr Haddad presented important data regarding perioperative complications in coronavirus positive patients undergoing surgical treatment of femoral neck fractures. In this multicenter cohort study from the United Kingdom 82 coronavirus positive patients were shown to have longer hospital stays, more critical care unit admissions, higher risk of perioperative complications and an increased mortality compared to 340 coronavirus negative patients. The eighth session had two papers on alternative femoral stem designs and three presentations more focused on femoral fracture treatments. Dr Mihalko focused on the European and US experiences with the Metha femoral neck retaining stem. The US experience mirrored the encouraging results from Europe with a 94% all cause femoral survivorship and a 99.1% femoral aseptic loosening survivorship at 5 years. Dr Kraay summarized dual energy x-ray absorptiometry (DEXA) evaluation of 16 low modulus composite femoral components at long-term follow-up of a mean 22 years. The bone mineral density associated with the implant increased in Gruen zones 2–6 and showed limited decreases in zones 1 and 7. These data support the concept that a low modulus femoral stem may more effectively load the proximal femur. Dr Springer provided data from the American Joint Replacement Registry (AJRR) and by evaluating outcomes of exact matched cohorts of 17,138 patients treated with cementless or cemented femoral implants for femoral neck fractures. Cemented implants were associated with marked reduction in early revision and periprosthetic fractures. However, cemented fixation was associated with an increased mortality at 90 days and 1 year. Additional data from the AJRR was presented by Dr Huddleston who investigated the risk factors for revision surgery after arthroplasty in a cohort of 75,333 femoral neck fractures. THA when compared to hemiarthroplasty was associated with higher early and overall revision rates. Cementless femoral fixation and increased age were also associated with higher rates of any revision. Both of these studies from the AJRR suggest that further consideration should be given to femoral fixation preferences in the femoral neck fracture population. Dr Vail summarized his institution's experience with an interdisciplinary hip fracture protocol for patients undergoing arthroplasty for acute femoral neck fractures. His study compared 157 cases prior to protocol implementation with 114 patients treated after the protocol was established. The impact of the interdisciplinary protocol was impressive as evidenced by a reduced time to operative treatment, length of stay, complication rate and one-year mortality. All being achieved without an increase in readmissions or facility discharges. The final session of the meeting addressed innovations in perioperative care of THA patients. Dr Barrack started the session with an interesting study examining the feasibility and patient preferences regarding telemedicine. A cross-sectional telephone survey of 163 arthroplasty patients indicated that 88% of patients use the internet and 94% own a device capable of videoconferencing. Nevertheless, only 18% of patients preferred a video visit over an in-person clinic visit due to concerns of inferior care. Dr Barnes quantified preoperative optimization work in 100 arthroplasty patients by using EMR activity logs and determined the surgical team spends an average 75 minutes per case on preoperative work activities. Dr Duwelius reported the early outcomes of primary THA with a smartphone-based exercise and educational platform compared to standard of care controls. A randomized control trial design with 365 patients demonstrated similar outcomes and non-inferiority of the smartphone platform relative to complications, readmissions, emergency room/urgent care visits. The association of controlled substance use with THA outcomes was assessed by Dr Higuera Rueda. A quantitative assessment using the NarxCare score identified 300 and above as a score associated with adverse outcomes after THA. Dr Macaulay reviewed data from a large retrospective study of 1,825 THAs indicating that discontinuation of intermittent pneumatic compression devices does not increase the risk of venous thromboembolism in standard risk patients being treated with 81mg ASA BID as prophylaxis. Dr Antoniou presented the final paper of the meeting investigating potential changes in patient health status as an indication for surgery over time. Data from this large systematic review of the literature found patients undergoing THA at similar health status to the past with no influence form patient age, gender, year of enrollment or geographic region. As summarized above, the 2020 virtual Hip Society Summer Meeting was rich in scientific content, productive discussion and a collaborative spirit. This collective body of work will result in impactful scientific contributions and will serve as a foundation for future innovation and advancements in the treatment of hip disease

Aims

The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC.

Introduction. In recent years the relationship between hyponatraemia and bone metabolism, falls and fractures has become more established. In this study hyponatraemia was an independent risk factor for increased post-operative mortality on multivariate analysis. Patients/Materials & Methods. This study retrospectively evaluates the prevalence of hyponatraemia (plasma sodium <135 mmol/l) in 3897 patients undergoing operative treatment for hip fracture and the relationship between hyponatraemia and mortality in these patients. Results. Median age at admission was 83 years. Hyponatraemia was present in 19.1% of patients with hip fracture on admission, 29.5% of patients within the first 24 hours post-operatively and 20% of patients at discharge. There was a significant association between hyponatraemia and time from admission to surgery indicating that patients admitted with hyponatraemia waited longer. Median follow-up time was 863 (range 0 – 4352) days. There were 2460 deaths (63.1% of the original 3897 patients) prior to the censor date. A total of 1144 patients (29.4% of the original 3897 patients) died within 12 months following discharge. Median survival following surgery was 39 weeks. Median time to death for patients with and without hyponatraemia on admission was 34 months (SE 1.7months) and 41 months (SE 2.5 months) respectively (p = 0.003). Median time to death for patients with and without hyponatraemia within 24 hours post-operatively was 35 months (SE 2.5 months) and 42 months (SE 1.7 months) respectively (p = 0.004). Following elimination of other independent variables associated with increased mortality, hyponatraemia on admission was associated with an increased risk of death (adjusted HR 1.15, p = 0.005). Post-operative hyponatraemia was also associated with an increased risk of death (adjusted HR 1.15, p = 0.006). Conclusion. Hyponatraemia is common in elderly patients with hip fractures both at initial presentation and during admission and is a potentially reversible cause of increased post-operative mortality

Persistent groin pain after seemingly successful total hip replacement (THR) appears to have become more common. Recent studies have indicated a high incidence after metal-on-polyethylene and metal-on-metal conventional THR and it has been documented in up to 18% of patients after metal-on-metal resurfacing. There are many causes, including acetabular loosening, stress fracture, and iliopsoas tendonitis and impingement. The evaluation of this problem requires a careful history and examination, plain radiographs and an algorithmic approach to special diagnostic imaging and tests. Non-operative treatment is not usually successful. Specific operative treatment depending on the cause of the pain usually involves revision of the acetabular component, iliopsoas tenotomy or other procedures, and is usually successful. Here, an appropriate algorithm is described

Aims

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

We have reviewed a group of patients with iliopsoas impingement after total hip replacement with radiological evidence of a well-fixed malpositioned or oversized acetabular component. A consecutive series of 29 patients (30 hips) was assessed. All had undergone a trial of conservative management with no improvement in their symptoms. Eight patients (eight hips) preferred continued conservative management (group 1), and 22 hips had either an iliopsoas tenotomy (group 2) or revision of the acetabular component and debridement of the tendon (group 3), based on clinical and radiological findings. Patients were followed clinically for at least two years, and 19 of the 22 patients (86.4%) who had surgery were contacted by phone at a mean of 7.8 years (5 to 9) post-operatively. Conservative management failed in all eight hips. At the final follow-up, operative treatment resulted in relief of pain in 18 of 22 hips (81.8%), with one hip in group 2 and three in group 3 with continuing symptoms. The Harris Hip Score was significantly better in the combined groups 2 and 3 than in group 1. There was a significant rate of complications in group 3. This group initially had better functional scores, but at final follow-up these were no different from those in group 2. Tenotomy of the iliopsoas and revision of the acetabular component are both successful surgical options. Iliopsoas tenotomy provided the same functional results as revision of the acetabular component and avoided the risks of the latter procedure

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.