Aims. Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233

Introduction. Debridement, antibiotics, and implant retention (DAIR) for acute prosthetic hip infection is a popular low morbidity option despite less than optimal success rates. We theorized that the delay between DAIR and explantation in failed cases may complicate eradication due to biofilm maturation and entrenchment of bacteria in periprosthetic bone. We ask, what are the results of two-stage reimplantation after a failed DAIR versus an initial two-stage procedure?. Methods. 114 patients were treated with 2-stage exchange for periprosthetic hip infection. 65 were treated initially with a 2-stage exchange, while 49 underwent an antecedent DAIR prior to a 2-stage exchange. Patients were classified according to MSIS host criteria. Failure was defined as return to the OR for infection, a draining sinus, or systemic infection. Results. Treatment failure occurred in 42.9% (21 of 49) of patients treated with an antecedent DAIR. In contrast, treatment failure occurred in only 12.3% (8 of 65) of initial 2-stage procedures (p< 0.001). Relative Risk of return to the OR after a 2-stage reimplantation with an antecedent DAIR compared to initial resection was 4.52 (95% CI 1.71, 11.9). MSIS host grading was similar between groups and did not influence the rate of failure. The DAIR cohort had increased hospitalization length and greater number of operative procedures (p< 0.001). Conclusion. We have shown that if irrigation and debridement fails to treat acute prosthetic hip infection, subsequent attempts at two-stage reimplantation may be compromised. Additionally, in the antecedent DAIR group, the average number of infection-related procedures (5) was nearly twice that of those initially resected (2.7). This by nature implies a significantly greater burden to the patient and cost to the healthcare system

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385).

The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development.

This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.

Aims. Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection. Patients and Methods. A total of 119 patients undergoing revision total hip arthroplasty (THA) between June 2015 and December 2017 were included in the study. There were 56 men and 63 women with a mean age of 66.2 years (27 to 88). Synovial fluid was collected before arthrotomy for the assessment of LE using enzymatic colourimetric strips. Between five and six samples were stained with haematoxylin and eosin for FS histology, and considered suggestive of infection when at least five polymorphonuclear leucocytes were found in five high-power fields. Results. The sensitivity and specificity of the LE assay were 100% and 93.8%, respectively; the positive (PPV) and the negative (NPV) predictive values were 79.3% and 100%, respectively. The mean time between the collection of the sample and the result being known was 20.1 minutes (. sd. 4.4). The sensitivity and specificity of FS histology were 78.3% and 96.9%, respectively; the PPV and the NPV were 85.7% and 94.9%, respectively. The mean time between the collection of the sample and the result being known was 27.2 minutes (. sd. 6.9). Conclusion. The sensitivity of LE assay was higher, with similar specificity and diagnostic accuracy, compared with FS histology. The faster turnaround time, its ease of use, and low costs make LE assay a valuable alternative to FS histology. We now use it routinely for the intraoperative diagnosis of PJI. Cite this article: Bone Joint J 2019;101-B:372–377

Introduction

Two-stage reimplantation for prosthetic joint infection (PJI) of the hip is the standard of care with a 5–10% recurrence at a minimum two-year follow-up. Compiling outcomes data for this standard of care is necessary in order to characterize long-term reinfection risk and the culpable microbiology. The purpose of this study was to determine the long-term success of two-stage reimplantation and identify the factors that affected the success.

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision necessitate removal of all bone cement from the femur. In our two institutions, we have been using a cement-in-cement technique, leaving the distal femoral cement in selected cases for septic hip revision surgery. Between February 2010 and September 2019, 89 patients with prosthetic hip infection underwent first or single stage procedures leaving the distal femoral cement in situ and performing a cement-in-cement revision. The mean patient age was 72.0 years (24–92). The median time from the last arthroplasty procedure was 29.0 months (1–294). 81 patients underwent revision using a cemented Exeter stem, 7 patients received an articulating spacer, and one patient underwent excision arthroplasty with the distal cement left in situ. Patients received clinical and radiographic follow-up with a mean of 42.8 months (range 11.0–120.1 months). Oxford hip scores were collected from each institution's existing databases. 9 patients (10.1%) died within one year of surgery. No deaths were directly related to joint infection or the surgery. One patient was lost to follow up before one year. Of the remainder, 7 patients (8.9%) required further procedures for infection and were therefore considered to be treatment failures. 6 patients (7.6%) underwent planned second stage procedures with no recurrence of infection. 7 patients (8.9%) had further surgery for non-infective reasons. The Kaplan-Meier estimate of infection free survival at one year was 93.7% (95% CI 88.4 to 99.0%). No patients underwent revision for stem loosening. Oxford hip scores were available at over one year postoperatively for 51 patients with a mean score of 30.6, and a mean gain of 11.9. In our combined cohort of patients, cement-in-cement revision had an infection eradication rate of 91.1%. Patient selection is crucial, and the procedure can only be performed when there is a well-fixed cement mantle. However, when strict criteria are followed, this technique offers potential significant benefits to surgeons performing this challenging surgery, and more importantly the patients undergoing them

Reliability of microbiological diagnosis of prosthetic joint infection [PJI] strongly depends on the ability to dislodge microorganisms from biofilm and on the rate of contaminating samples during collection in the operating room and processing. The aim of a correct protocol is to avoid false negative and false positive results in order to adapt the correct therapy for each patient. The object of the present study was to evaluate the impact of a novel closed bag system designed for samples collection and processing based on dithiothreitol (DTT), which is a sulfydryl compound able to remove bacteria from biofilm (MicroDTTect, 4i, Italy), on isolation of contaminant microorganisms in hip prostheses. Specimens (prostheses, spacers, periprosthetic tissues) were aseptically collected according to a standard protocol into the device, which was transported to the laboratory for culture. Three different models of the system were prospectively evaluated, each being a development of the previous one. The first generation device consisted in an “open” system (DTT eluate was collected with a syringe and dispensed into sterile tubes), the second generation device in a “partially closed” system (DTT eluate collected directly in sterile vacuum tubes) and the third generation device in a “completely closed system” (DTT reservoir directly connected with sealed tubes inside the device). PJI was diagnosed following criteria established by MSIS. The overall contamination rate, sensitivity and specificity of the first generation “open” system MicroDTTect were respectively 2.6% (1/39), 82.3% and 95.4% in 39 hips. The second generation “partially closed” device was characterized by a contamination rate of 1.96% (1/51), a sensitivity of 84% and a specificity of 96.1% in 51 hips. Contamination rate further decreased in the third generation “closed” system (1.89%, 2/106), while sensitivity (91.3%) and specificity (96.7%) improved in 106 hips. Differences have been also observed in hips (106) when compared to knees (70 cases) prosthetic infections (sensitivity 91.3% vs 89.3% and specificity 96.7% vs 100%). Our data show as, thanks to its ease of use, low contamination rate and high sensitivity, MicroDTTect can represent a useful tool for improving the microbiological diagnosis of PJIs in hip revisions and has replaced sonication in our practice

Introduction. Fluorodeoxuglucose(FDG) Positron Emission Tomography(PET) scan is used in the diagnosis of prosthetic joint infection, when the inflammatory markers and aspiration of the joint do not establish a definitive diagnosis. The aim of our study was to analyse the utility of FDG PET scan in decision making in these patients. Methods. We performed a prospective study of patients who underwent a FDG PET scan for suspected prosthetic hip infection, between September 2013 and July 2017. We analysed the results of aspiration, culture and sensitivity, histology of intra-operative samples and inflammatory markers. Our gold standard for diagnosis of infection was 3 or more positive cultures of the same organism. Diagnostic utility statistics for FDG PET were performed. Results. 55 revisions total hip replacements were included. The mean age of the patients was 67.5±4.85 years. The mean ESR, CRP and WCC were 19.83 mm/hr, 22.21 mg/l and 9.05×10. 9. /l respectively. The sensitivity and specificity for FDG PET were 93.75% and 35.89% respectively. The positive predictive value(PPV) was 37.5% and negative predictive value(NPV) was 93.33%. The accuracy of detecting an infection was 52.7%. The false positive rate was 62.5%. Discussion. FDG PET has a large number of false positive results and low specificity. If the inflammatory markers and aspiration do not establish infection, addition of FDG PET has limited accuracy in confirming the diagnosis of prosthetic joint infection. Conclusion. FDG PET may be useful for ruling out infection, but a positive result may not indicate the presence of infection

Introduction. There has been a renewed interest in the surgical approach used for total hip arthroplasty (THA). Risk factors for periprosthetic joint infection (PJI) have been well studied over the past decade, yet PJI remains one of the most devastating complications following THA. We studied the impact of direct anterior (DA) versus non-direct anterior (NA) surgical approaches on PJI, and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. Methods. 6086 continuous patients undergoing primary THA at a single institution from 2013–2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. Deep PJI was defined according to National Healthcare Safety Network's (NHSN) criteria for joint space infection following prosthetic hip replacement. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios for risk of development of PJI with DA compared to NA approaches. In order to determine the effect of adopting a set of infection prevention protocols and patient optimization on PJI, we calculated odds ratios for PJI comparing patients undergoing THA for two distinct time periods: 2013–2014 and 2015–2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. Results. There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJI's in the DA group (1.22%) and 26 deep PJI's in the NA group (0.63%) (p=0.0231). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (95% CI OR 1.1–3.9, p=0.0062) for the overall study period. When stratified by time, patients undergoing THA utilizing any approach prior to adopting the infection prevention protocols (2013–2014), were 1.8 times more likely to have PJI compared to patients undergoing THA after the adoption of the protocols, however this result did not reach significance (95% CI OR 0.901–3.653, p=0.0953). Conclusions. We found a higher rate of PJI in DA versus NA approaches. However, adoption of infection prevention protocols patient optimization mitigated these PJI rates, such that they were equalized between the approach groups for the period following the use of infection prevention and patient optimization protocols. Institutional learning curves and adaptation of interventions aimed at PJI prevention positively contributed to the decreased rate of PJI observed for all approaches over time. Evidence: Level II – Case control

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

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

Current treatments of prosthetic joint infection (PJI) are minimally effective against Staphylococcus aureus biofilm. A murine PJI model of debridement, antibiotics, and implant retention (DAIR) was used to test the hypothesis that PlySs2, a bacteriophage-derived lysin, can target S. aureus biofilm and address the unique challenges presented in this periprosthetic environment.

Aims

Single-stage revision is not widely pursued due to restrictive inclusion criteria. In this study, we evaluated the results of single-stage revision of chronically infected total hip arthroplasty (THA) using broad inclusion criteria and cementless implants.

Aims

To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon.

Objectives

The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient’s recollection of their own preoperative OHS and OKS one year following surgery.

Objectives

T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty.

Conventional cemented acetabular components are reported to have a high rate of failure when implanted into previously irradiated bone. We recommend the use of a cemented reconstruction with the addition of an acetabular reinforcement cross to improve fixation.

We reviewed a cohort of 45 patients (49 hips) who had undergone irradiation of the pelvis and a cemented total hip arthroplasty (THA) with an acetabular reinforcement cross. All hips had received a minimum dose of 30 Gray (Gy) to treat a primary nearby tumour or metastasis. The median dose of radiation was 50 Gy (Q1 to Q3: 45 to 60; mean: 49.57, 32 to 72).

The mean follow-up after THA was 51 months (17 to 137). The cumulative probability of revision of the acetabular component for a mechanical reason was 0% (0 to 0%) at 24 months, 2.9% (0.2 to 13.3%) at 60 months and 2.9% (0.2% to 13.3%) at 120 months, respectively. One hip was revised for mechanical failure and three for infection.

Cemented acetabular components with a reinforcement cross provide good medium-term fixation after pelvic irradiation. These patients are at a higher risk of developing infection of their THA.

Cite this article: Bone Joint J 2015;97-B:177–84.

There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups.

In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables.

Total hip replacement (THR) still is a rare intervention in many African countries. In Burkina Faso it is not performed on a regular basis. A visiting programme for THR was started in a district hospital with no previous relevant experience. In this paper we present an analysis of the surgical technical problems and peri-operative complications of 152 THRs in 136 patients and three bipolar hemiarthroplasties in three patients undertaken in this new programme with limited orthopaedic equipment. There were 86 male and 53 female patients with a mean age of 49 years (21 to 78). We identified 77 intra-operative technical problems in 51 operations. There were 24 peri-operative complications in 21 patients, 17 of which were bony in nature. So far, ten revision THRs have been performed in nine patients.

Regular analysis of the technical problems and complications was used to improve quality, and we identified patient selection adapted to the local circumstances as important to avoid complications. Our reflections on the problems encountered in initiating such a programme may be of help to other teams planning similar projects.

Cite this article: Bone Joint J 2014;96-B:177–80.

We report the kinematic and early clinical results of a patient- and observer-blinded randomised controlled trial in which CT scans were used to compare potential impingement-free range of movement (ROM) and acetabular component cover between patients treated with either the navigated ‘femur-first’ total hip arthroplasty (THA) method (n = 66; male/female 29/37, mean age 62.5 years; 50 to 74) or conventional THA (n = 69; male/female 35/34, mean age 62.9 years; 50 to 75). The Hip Osteoarthritis Outcome Score, the Harris hip score, the Euro-Qol-5D and the Mancuso THA patient expectations score were assessed at six weeks, six months and one year after surgery. A total of 48 of the patients (84%) in the navigated ‘femur-first’ group and 43 (65%) in the conventional group reached all the desirable potential ROM boundaries without prosthetic impingement for activities of daily living (ADL) in flexion, extension, abduction, adduction and rotation (p = 0.016). Acetabular component cover and surface contact with the host bone were > 87% in both groups. There was a significant difference between the navigated and the conventional groups’ Harris hip scores six weeks after surgery (p = 0.010). There were no significant differences with respect to any clinical outcome at six months and one year of follow-up. The navigated ‘femur-first’ technique improves the potential ROM for ADL without prosthetic impingement, although there was no observed clinical difference between the two treatment groups.

Cite this article: Bone Joint J 2015; 97-B:890–8.