Aims. Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. Methods. In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment. Results. The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6. o. (SD 7.9. o. ) to 1.8. o. (SD 2.4. o. ; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months. Conclusion. Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity. Cite this article: Bone Jt Open 2021;2(9):696–704

The trend towards more minimal access has led to a series of instruments being developed to enable adequate access for Direct Anterior Approach (DAA) for hip arthroplasty. These include longer levers, hooks attached to the operating table and a series of special attachments to the operating table to position the leg and apply traction where necessary. The forces applied in this way may be transmitted locally, damaging muscle used as a fulcrum, or the knee and ankle joints when torque has to be applied to the femur through a boot. The arthroplasty surgeon's aim is to minimise the forces applied to both bone and soft tissue during surgery. We surmised that the forces needed for adequate access were related to the extent of the capsular and soft tissue releases, and that they could be measured and optimised. with the aim of minimising the forces applied to the tissues around the hip. Eight fresh frozen specimens from pelvis to mid tibia from four cadavers were approached using the DAA. A 6-axis force/torque sensor and 6-axis motion tracking sensor were attached to a threaded rod securely fastened to the tibial and femoral diaphysis. The torque needed to provide first extension, then external rotation, adequate for hip arthroplasty were measured as the capsular structures were divided sequentially. The Zona Orbicularis (ZO) and Ischiofemoral Ligament(IFL) contributed most of the resistance to both extension (4.0 and 3.1Nm) and external rotation torque (5.8 and 3.9Nm). The contributions of the conjoint tendon (1.5 and 2.4Nm) and piriformis (1.2 and 2.3Nm) were substantially smaller. By releasing the Zona Orbicularis and Ischiofemoral Ligament, the torque needed to deliver the femur for hip arthroplasty could be reduced to less than the torque needed to open a jar (2.9–5.5Nm)

Surgical treatment of Hip PJI by resection of the infected implants and tissue and placement of a “spacer” which elutes antibiotic via antibiotic loaded cement is an accepted treatment option. There is some controversy over whether this “spacer” should be articulating or static. Proponents of the articulating option argue that there is improved function and maintenance of the soft tissue envelop. Critics have suggested that additional biomaterials may compromise eradication of infection. This study compares our results of the 2 treatment options. A review of our institutional PJI database between 2016 and 2021 identified 87 patients who were treated with resection arthroplasty for unilateral total hip PJI. The cohort was analyzed for demographics and type for surgery, as well as medical comorbidities, survivorship, and treatment success. 44 patients were female, the mean age of all patients was 62. 44 patients were treated with Articulating apacers, and 43 patients treated with static spacers. There was no significant difference between ASA or Elixhauser score, and no significant difference between mortality or treatment failure. This study did not show any difference between the patients who receive static spacers, from those who received articulating spacers, and deomstrated similar treatment success rates. From this data there does not appear to be any difference in success rates between those patients that were treated with static spacers and those that were treated with articulating spacers

Ideally the hip arthroplasty should not be subject to bony or prosthetic impingement, in order to minimise complications and optimise outcomes. Modern 3d planning permits pre-operative simulation of the movements of the planned hip arthroplasty to check for such impingement. For this to be meaningful, however, it is necessary to know the range of movement (ROM) that should be simulated. Arbitrary “normal” values for hip ROM are of limited value in such simulations: it is well known that hip ROM is individualised for each patient. We have therefore developed a method to determine this individualised ROM using CT scans. CT scans were performed on 14 cadaveric hips, and the images were segmented to create 3d virtual models. Using Matlab software, each virtual hip was moved in all potential directions to the point of bony impingement, thus defining an individualised impingement-free 3d ROM envelope. This was then compared with the actual ROM as directly measured from each cadaver using a high-resolution motion capture system. For each hip, the ROM envelope free of bony impingement could be described from the CT and represented as a 3d shape. As expected, the directly measured ROM from the cadaver study for each hip was smaller than the CT-based prediction, owing to the presence of constraining soft tissues. However, for movements associated with hip dislocation (such as flexion with internal rotation), the cadaver measurements matched the CT prediction, to within 10°. It is possible to determine an individual's range of clinically important hip movements from a CT scan. This method could therefore be used to create truly personalised movement simulation as part of pre-operative 3d surgical planning

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

Traditional mechanical debridement can only remove visibly infected tissue and is unable to completely clear all the biofilm that hides within muscle crevices and nerves. This study aims to determine the results of single-stage revision using noncontact low frequency ultrasonic debridement in treating chronic periprosthetic joint infections (PJI). A prospective study of consecutive patients requiring single-stage revision for chronic PJI was performed since August 2021. After mechanical debridement, an 8‑mm handheld non‑contact low‑frequency ultrasound probe was used for ultrasonic debridement at a frequency of (25±5) kHz and power of 90% for 5 minutes. Each ultrasound lasted 10 seconds with 3‑seconds intervals. The probe was repeatedly sonicated among all soft tissue and bsingle interface. The distal femoral canal and the posterior capsule of the knee were fully sonicated with a special right‑angle probe. Chemical debridement was then performed to irrigation the whole operative area. Recurrence of infection, culture results and number of colonies 24 hours after ultrasonic debridement were recorded. A total of 45 patients (25 hips and 20 knees) were included and 43 of them (95.6%) were free of infection at a mean follow-up time of 29 months (24 to 33). There were no intraoperative complications related to ultrasonic debridement (neurovascular and muscle injury, poor wound healing and fat liquefaction). The culture‑positive rate of wound liquid before ultrasonic debridement was 40.0% (18/45), which significantly increased to 75.6% (34/45) after ultrasonic debridement (P=0.001). The median number of colonies 24 hours after ultrasonic debridement was 2372 CFU/ml (310 to 4340 CFU/ml), which was significantly higher than that before debridement (307 CFU/ml; 10 to 980 CFU/ml) (P=0.000). Single-stage revision with non‑contact low‑frequency ultrasonic debridement can fully expose bacteria within biofilm, increase the efficacy of chemical debridement and lead to a favorable short‑term outcome without related complications

Dislocation following revision THA remains a leading cause of failure. Integrity of the abductor muscles is a major contributor to stability. Large diameter heads (LDH), Dual Mobility (DM) and Constrained Acetabular Liners (CAL) are enhanced stability options but the indication for these choices remains unclear. We assessed an algorithm based on Gluteus Medius (GM) deficiency to determine bearing selection. Default choice with no GM damage was a LDH. GM deficiency with posterior muscle intact received DM and CAL for GM complete deficiency with loss of posterior muscle. Consecutive revision THA series followed to determine dislocation, all-cause re-revision and Oxford Hip Score (OHS). 311 revision THA with mean age 70 years (32–95). At a mean follow-up of 4.8 years overall dislocation rate 4.1% (95%CI 2.4–7.0) and survivorship free of re-revision 94.2% (95%CI 96.3–91.0). Outcomes:. Group 1 - LDH (36 & 40mm) n=164 / 4 dislocations / 7 re-revisions. Group 2 - DM n=73 / 3 dislocations / 4 re-revisions. Group 3 - CAL n=58 / 5 dislocations / 7 re-revisions. Group 4 - Other (28 & 32mm) n=16 / 1 dislocation / no re-revisions. Mean pre-op OHS: 19.6 (2–47) and mean post-op OHS: 33.9 (4–48). Kaplan-Meier analysis at 60 months dislocation-free survival was 96.1% (95% CI: 93.0–97.8). There was no difference between survival distributions comparing bearing choice (p=0.46). Decision making tools to guide selection are limited and in addition soft tissue deficiency has been poorly defined. The posterior vertical fibres of GM have the greatest lateral stabiliser effect on the hip. The algorithm we have used clearly defined indication & implant selection. We believe our outcomes support the use of an enhanced stability bearing selection algorithm

Dual Mobility (DM) Total Hip Replacements (THRs) were introduced to reduce dislocation risk, which is the most common cause of early revision. The in-vivo mechanics of these implants is not well understood, despite their increased use in both elective and trauma settings. Therefore, the aim of this study was to comprehensively assess retrieved DM polyethylene liners for signs of damage using visual inspection and semi-quantitative geometric assessment techniques. Retrieved DM liners (n=20) were visually inspected for the presence of seven established modes of polyethylene damage. If embedded debris was identified on the external surface, its material composition was characterised using energy-dispersive x-ray analysis (EDX). Additionally, each liner was geometrically assessed for signs of wear/deformation using a validated methodology. Visual inspection of the liners revealed that scratching and pitting were the most common damage modes on either surface. Burnishing was observed on 50% and 15% of the internal and external surfaces, respectively. In addition, embedded debris was identified on 25% of the internal and 65% of the external surfaces. EDX analysis of the debris identified several materials including iron, titanium, cobalt-chrome, and tantalum. Geometric analysis demonstrated highly variable damage patterns across the liners. The results of this study provide insight into the in-vivo mechanics of DM bearings. For example, the results suggest that the internal bearing (i.e., between the head and liner) acts as the primary articulation site for DM-THRs as evidenced by a higher incidence of burnishing and larger, more concentrated regions of penetration across the liners’ internal surfaces. Furthermore, circumferential, and crescent-shaped damage patterns were identified on the articulating surfaces of the liners thus providing evidence that these components can rotate within the acetabular shell with varying degrees of mobility. The mechanics of DM bearings are complex and may be influenced by several factors (e.g., soft tissue fibrosis, patient activities) and thus further investigation is warranted. Finally, the results of this study suggest that DM liners may be susceptible to ex-vivo surface damage and thus caution is advised when handling and/or assessing these types of components

The direct anterior approach (DAA) is a popular minimally invasive approach for total hip arthroplasty (THA). It usually involves ligation of the lateral femoral circumflex artery's ascending branch (a-LFCA), which contributes to the perfusion of the tensor fasciae latae (TFL) muscle. Periarticular muscle status and clinical outcome were assessed after DAA-THA after a-LFCA preservation versus ligation. We evaluated surgical records of 161 patients undergoing DAA-THA with tentative preservation of the a-LFCA by the senior author between May and November 2021. Among 92 eligible patients, 33 (35 hips) featured successful preservation, of which 20 (22 hips, 13 female) participated in the study. From 59 patients with ligated a-LFCA, 26 (27 hips, 15 female) were enrolled, constituting the control group. MRI and clinical examinations were performed at 17–26 months to analyze volume and fatty infiltration of the TFL, gluteus medius and gluteus minimus muscles relative to the contralateral non-THA hip (15 preserved, 18 ligated). Clinical and radiographic data was retrospectively extracted from patient files. Patient-reported outcomes (PROMs) were added from the THA registry. There was a relative difference in TFL muscle volume of -6.27 cm. 3. (−9.89%, p=0.018) after a-LFCA preservation versus -8.6 cm. 3. (=11.62%, p=0.002) after ligation, without group differences (p>0.340). a-LFCA preservation showed lower relative TFL fatty infiltration (p=0.10). Gluteal muscle status was similar between sides and groups. Coxa valga morphology was more frequent in a-LFCA preservation (83%) than ligation (17%). Clinical outcomes showed high patient satisfaction in both groups, without difference in PROMs, but less anterolateral soft-tissue swelling after a-LFCA preservation (p<0.001). Despite excellent clinical results in both groups, preservation of the a-LFCA was associated with less TFL fatty infiltration and soft tissue swelling. Provided there is no compromise of intraoperative access we recommend a-LFCA preservation for DAA-THA

Executing an extended retinacular flap containing the blood supply for the femoral head, reduction osteotomy (FHO) can be performed, increasing the potential of correction of complex hip morphologies. The aim of this study was to analyse the safety of the procedure and report the clinical and radiographic results in skeletally mature patients with a minimum follow up of two years. Twelve symptomatic patients (12 hips) with a mean age of 17 years underwent FHO using surgical hip dislocation and an extended soft tissue flap. Radiographs and magnetic resonance imaging producing radial cuts (MRI) were obtained before surgery and radiographs after surgery to evaluate articular congruency, cartilage damage and morphologic parameters. Clinical functional evaluation was done using the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). After surgery, at the latest follow-up no symptomatic avascular necrosis was observed and all osteotomies healed without complications. Femoral head size index improved from 120 ± 10% to 100 ± 10% (p<0,05). Femoral head sphericity index improved from 71 ± 10% before surgery to 91 ± 7% after surgery (p<0,05). Femoral head extrusion index improved from 37 ± 17% to 5 ± 6% (p< 0,05). Twenty five percent of patients had an intact Shenton line before surgery. After surgery this percentage was 75% (p<0,05). The NAHS score improved from a mean of 41 ± 18 to 69 ± 9 points after surgery (p< 0,05). The HOS score improve from 56 ± 24 to 83 ± 17 points after surgery (p< 0,05) and the mHHS score improved from 46 ± 15 before surgery to 76 ± 13 points after surgery (p< 0,05). In this series, femoral head osteotomy could be considered as safe procedure with considerable potential to correct hip deformities and improve patients reported outcome measures (PROMS). Level of evidence - Level IV, therapeutic study. Keywords - Femoral head osteotomy, Perthes disease, acetabular dysplasia, coxa plana

After a hip fracture, infections are common, but signs of infection resemble those of systemic inflammatory response to trauma and surgery, and conventional infection markers lack specificity. Plasma-calprotectin, a novel marker of neutrophil activation, has shown potential as an infection marker in ER and ICU settings. To investigate if plasma-calprotectin is superior compared to conventional infection biomarkers after hip fracture. Prospective cohort study of hip fracture patients admitted to our department. Calprotectin, procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) count were measured in blood plasma upon admission and on day 3 post-surgery. Patients with infection (pneumonia, UTI, sepsis, SSI, other soft tissue infections) pre- or post-surgery were compared to a control group without infection within 30 days. Statistics: Wilcoxon rank-sum test, medians with interquartile range, and area under the curve (AUC) with 95% confidence intervals. Pilot study comprises calprotectin obtained at least once for 60 patients at admission and 48 on day 3. Mean age 84 years (SD 8.4), 65% women. 9/60 patients (23%) were admitted with infections. They had higher levels of CRP (median 111 [73-149]) and PCT (0.35 [0.18–0.86]) compared to the control group (29 [16-64], p=0.037; 0.10 [0.07–0.17], p=0.007). Calprotectin (2.67 vs 2.51) and WBC (12.2 vs 9.3) did not differ significantly. AUC was highest for PCT (0.79 [CI 0.60–0.97]), followed by CRP (0.71 [0.46–0.96]), WBC (0.60 [0.35–0.84]), and calprotectin (0.58, [0.33–0.83]). Day 3, 6/48 (13%) had infections, without significant differences between groups in any marker. The median levels were: calprotectin 3.5 vs 3.1, CRP 172 vs 104, WBC 12 vs 9, PCT 0.16 vs 0.17. Calprotectin had highest AUC 0.68 (0.41–0.93, n.s.). AUC for WBC was 0.67 (0.31–1.00), CRP 0.66 (0.38–0.94), PCT 0.56 (0.29–0.82). Preliminary data show no significant associations with postoperative infection for any of the studied biomarkers. However, plasma-calprotectin might perform slightly better compared to conventional markers

Cobalt chrome alloy is commonly used in joint replacement surgery. However, it is recognised that some patients develop lymphocyte mediated delayed type hypersensitivity (DTH) responses to this material, which may result in extensive bone and soft tissue destruction. Phase 1. United Kingdom: From an existing database, we identified extreme phenotype patient groups following metal on metal (MoM) hip resurfacing or THR: ALVAL with low wearing prostheses; ALVAL with high wear; no ALVAL with high wear; and asymptomatic patients with implants in situ for longer than ten years. Class I and II HLA genotype frequency distributions were compared between these patients’ groups, and in silico peptide binding studies were carried out using validated methodology. Phase 2. United Kingdom: We expanded the study to include more patients, including those with intermediary phenotypes to test whether an algorithm could be developed incorporating “risk genotypes”, patient age, sex and metal exposure. This model was trained in phase 3. Phase 3. United Kingdom, Australia, United States. Patients from other centres were invited to give DNA samples. The data set was split in two. 70% was used to develop machine learning models to predict failure secondary to DTH. The predictions were tested using the remaining blinded 30% of data, using time-dependent AUROCs, and integrated calibration index performance statistics. A total of 606 DNA samples, from 397 males and 209 female patients, were typed. This included 176 from patients with failed prostheses, and 430 from asymptomatic patients at a mean of >10 years follow up. C-index and ROC(t) scores suggested a high degree of discrimination, whilst the IBS indicated good calibration and further backed up the indication of high discriminatory ability. At ten years, the weighted mean survival probability error was < 4%. At present, there are no tests in widespread clinical use which use a patient's genetic profile to guide implant selection or inform post-operative management. The algorithm described herein may address this issue and we suggest that the application may not be restricted to the field of MoM hip arthroplasty

Background. Instability is one of the most common complications after total hip arthroplasty (THA), particularly when using the posterior approach. Repair of the posterior capsule has proven to significantly decrease the incidence of posterior hip dislocation. The purpose of the present study is to evaluate if braided polyblend suture provides a stronger repair of the posterior soft tissues when compared to a non-absorbable suture repair after a posterior approach to the hip. Methods. Ten cadaveric hips from donors who were a mean (and standard deviation) of 80 ± 9 years old at the time of death were evaluated after posterior soft tissue repair utilizing two different techniques. Five specimens were repaired using no. 2 non-absorbable sutures while five specimens had a repair utilizing braided polyblend suture with a rucking hitch knot technique. Cadaveric specimens were matched based upon age, sex, and laterality. Biomechanical tensile testing using the Instron E10000 Mechanical Testing System and the mechanism of failure were assessed. Results. The ultimate load to failure was three times higher using braided polyblend suture (390.00 ± 129.08 N) compared to non-absorbable sutures (122.81 ± 82.41 N) after posterior soft tissue repair (P<.01). In the braided polyblend suture cohort, the mechanism of failure occurred as the braided suture pulled through the posterior soft tissues. However, in the non-absorbable suture repair, failure took part at the suture knot. Conclusion. The use of our braided polyblend suture technique provides for a stronger repair of the posterior soft tissues when compared to non-absorbable suture repair following a posterior approach to the hip joint

The duration of systemic antibiotics following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, high concentration of targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy for two-stage hip revision. A retrospective review of our Institution's prospective database was performed to identify all intended two-stage hip revision procedures for PJI. All patients had a confirmed PJI as per MSIS 2013 criteria, minimum 5-years follow up and outcomes according to the MSIS working group outcome-reporting tool; then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year). 383 intended two-stage hip revisions were identified; of which 299 met our inclusion criteria, in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage). Median follow up was 10.7 years (IQR 6.3 – 15.0). 258 (86%) patients proceeded to 2. nd. stage surgery. 91% success rate was observed for those patients who underwent reimplantation, although dropping to 86% when including the patients who did not proceed to second stage. The median duration of post-operative systemic antibiotics was 5 days (IQR 5–9). No significant difference was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed with two-stage exchange or gram-positive PJI (86%); than for gram-negative PJI (81%) and polymicrobial infection (74%) (p=0.36). Fungal PJI was observed to have a significantly reduced rate of success (n=3; 33%; p=0.03). Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage to manage PJI of the hip provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs

Aims. Previous research has demonstrated increased early complication rates following total hip arthroplasty (THA) in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth (FD) has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery, as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peritrochanteric FD was associated with an increased risk of complications in the first year following THA. Methods. We analyzed prospectively collected data on a consecutive series of 1,220 primary THAs from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured intraoperatively using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient’s preoperative assessment. All surgical complications occuring within the initial 12 months of follow-up were identified. Results. Females had a significantly greater FD at the greater trochanter in comparison to males (median 3.0 cm (interquartile range (IQR) 2.3 to 4.0) vs 2.0 cm (IQR 1.7 to 3.0); p < 0.001) despite equivalent BMI between sexes (male median BMI 30.0 kg/m. 2. (IQR 27.0 to 33.0); female median 29.0 kg/m. 2. (IQR 25.0 to 33.0)). FD showed a weak correlation with BMI (R² 0.41 males and R² 0.43 females). Patients with the greatest FD (upper quartile) were at no greater risk of complications compared with patients with the lowest FD (lower quartile); 7/311 (2.3%) vs 9/439 (2.1%); p = 0.820 . Conversely, patients with the highest BMI (≥ 40 kg/m. 2. ) had a significantly increased risk of complications compared with patients with lower BMI (< 40 kg/m. 2. ); 5/60 (8.3% vs 18/1,160 (1.6%), odds ratio (OR) 5.77 (95% confidence interval (CI) 2.1 to 16.1; p = 0.001)). Conclusion. We found no relationship between peritrochanteric FD and the risk of surgical complications following primary THA. Cite this article: Bone Joint J 2020;102-B(9):1146–1150

Background. Fully constrained liners are used to treat recurrent dislocations or patients at high risk after total hip replacements. However, they can cause significant morbidities including recurrent dislocations, infections, aseptic loosening and fractures. We examine long term results of 111 patients with tripolar constrained components to assess their redislocation and failure rate. Questions/purposes. The purpose of this study was to assess survivorship, complications and functional outcomes at a minimum 10 years after the constrained tripolar liners used in our institute. Methods. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1998 and 2008. Eighty-nine were revised due to recurrent dislocations, 11 for pseudotumor with deficient abductors, and 13 for periprosthetic infection with loss of soft tissue stabilizers. All patients had revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 had more than 3 revisions. We extracted demographics, implant data, rate of dislocations and incidence of other complications. Kaplan Meier curves were used to assess dislocation and failure for anything reason. WOMAC was used to assess quality of life. Results. At 10 years, the survival free of dislocation was 95.6% (95%CI 90– 98), and at 20 years to 90.6% (95% CI 81.0– 95.5). Eight patients (7.1%) had dislocations of their constrained liners: 1 patient had simultaneous periprosthetic infection identified at the time of open reduction, and 1 patient sustained stem fracture 3 months prior to the liner dislocation. At 10 years, the survival to any further surgery was 89.4% (95% CI 82–93.8), and at 20 years, this was 82.5 (95% CI 71.9–89.3). Five patients (4.4%) had deep infection: 4 of these had excision arthroplasty due to failure to control infection, while 1 patient was treated successfully with debridement, exchange of mobile components and intravenous antibiotics. Two patients (1.8%) had dissociated rings that required change of liner, ring and head. Two patients (1.8%) had periprosthetic femoral fractures that were treated by revision stems and exchange of constrained liners. The mean WOMAC functional and pain scores were 66.2 and 75.9 of 100, respectively. Conclusions. Constrained tripolar liners in our institute provided favourable results in the long term for recurrent dislocation hip arthroplasty with dysfunctional hip stabilizers. Infection in these patients can prove to be difficult to treat due to their poor soft tissue conditions from repeated surgeries. Comparing long term results from other types of constrained liners is essential to evaluate these salvage liners

Hip arthroscopy is a rapidly expanding technique that has a steep learning curve. Simulation may have a role in helping trainees overcome this. However there is as yet no validated hip arthroscopy simulator. This study aimed to test the construct validity of a virtual reality hip arthroscopy simulator. Nineteen orthopaedic surgeons performed a simulated arthroscopic examination of a healthy hip joint in the supine position. Surgeons were categorized as either expert (those who had performed 250 hip arthroscopies or more) or novice (those who had performed fewer than this). Twenty-one targets were visualized within joint; nine via the anterior portal, nine via the anterolateral and three via the posterolateral. This was followed by a task testing basic probe examination of the joint in which a series of eight targets were probed via the anterolateral portal. Each surgeon's performance was evaluated by the simulator using a set of pre-defined metrics including task duration, number of soft tissue & bone collisions, and distance travelled by instruments. No repeat attempts at the tasks were permitted. Construct validity was then evaluated by comparing novice and expert group performance metrics over the two tasks using the Mann–Whitney test, with a p value of less than 0.05 considered significant. On the visualization task, the expert group outperformed the novice group on time taken (P=0.0003), number of collisions with soft tissue (P=0.001), number of collisions with bone (P=0.002) and distance travelled by the arthroscope (P=0.02). On the probe examination, the two groups differed only in the time taken to complete the task (P=0.025). Increased experience in hip arthroscopy was reflected by significantly better performance on the VR simulator across two tasks, supporting its construct validity. This study validates a virtual reality hip arthroscopy simulator and supports its potential for developing basic arthroscopic skills

Introduction. Open and arthroscopic hip debridement may be used for treatment of femoral acetabular impingement (FAI). There is a paucity of evidence regarding the efficacy of one over the other. Aim. To compare survivorship in terms of further surgical procedure at five years, in patients having undergone either arthroscopic or open hip debridement. Methods. Using our institutional database, we identified all post learning curve arthroscopic and open hip debridement cases with five years of follow up. Patients were matched based on age, gender and Tonnis grade. The primary outcome measure was 5 year survivorship to total hip arthroplasty (THA). Secondary outcome measures included 5 year survivorship to further (non THA) procedures on the joint. Radiological parameters were analysed including femoral neck version, sourcil, centre-edge and alpha angles. Results. A total of 390 arthroscopic and 1316 open operations were identified. Following exclusion and matching 102 (62 female, 39 male) cases were available for analysis in each group. Mean age was 36 years (range 17–51). At 5 years 14.8% of arthroscopic debridement patients and 5.9% of open debridement patients had undergone THA (p =0 .038). There was no statistical difference in secondary outcome measures. Discussion. A significantly higher percentage of patients undergoing arthroscopic debridement went on to THA when compared to matched patients receiving open debridement. We acknowledge the limitations of this study. However, despite the increasing prevalence of arthroscopic surgery to treat FAI, our results would suggest that open debridement may still remain the gold standard intervention. Further investigation, ideally in the form of an RCT, is warranted. Conclusion. In our case matched series, despite the longer rehabilitation and greater soft tissue insult, open surgery for FAI was associated with significantly less patients progressing to THA within 5 years compared to those undergoing arthroscopic debridement

Introduction. Previous research has demonstrated increased early complication rates following total hip arthroplasty in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peri-trochanteric fat depth was associated with increased risk of early complication following total hip arthroplasty. Methods. We analysed prospectively collected data on a consecutive series of 1220 patients undergoing primary total hip arthroplasty from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient's pre-operative assessment review. All complications (infection, dislocation and peri-prosthetic fracture) occuring within the initial 12 month follow-up were identified. Results. Females had a significantly greater fat depth at the greater trochanter in comparison to males (median 3.0cm (IQR 2.3–4.0) versus 2.0cm (IQR 1.7–3.0), p<0.001) despite equivalent BMI between genders (males median BMI 30.0 (IQR 27.0–33.0); female median 29.0 (IQR 25.0–33.0). Fat depth had a weak correlation with BMI (R. 2. 0.41 males and R. 2. 0.43 females). Patients with the greatest fat depth (upper quartile) were at no greater risk of developing a complication compared to patients with the lowest fat depth (lower quartile); 2% vs 1.8%, p=0.829. Conclusions. Peri-trochanteric fat depth is only weakly correlated with BMI. We found no correlation between increased fat depth and risk of early complication following primary total hip arthroplasty

Introduction. Enhanced stability using dual mobility has been demonstrated but concerns about potential for corrosion in modular versions have been raised. Case reports of corrosion with malseated inserts have heightened concerns over this modularity. Some have claimed that malseating is rare, the true frequency is unknown. The purpose of our investigation was to determine the incidence of liner malseating in dual mobility implants at our institution. Methods. 567 hips had primary modular dual mobility hip replacements (Biomet or Stryker) between 2016 and 2018. Post-operative radiographs were reviewed independently by two reviewers to identify malseating. Liners were considered malseated if there was a noticeable gap between the metal liner and acetabular shell(figure 1). All liners deemed to be malseated were independently assessed by 3 separate reviewers for confirmation. Results. 32 of the 567 (5.6%) of the liners were found to be malseated. There were no malseated liners in the Biomet group (n=46). There were 32 malseated liners in 521 (6.1%) Stryker cups using 3 different Stryker shells: 19 of 229 (8.23%) in the Trident I hemispherical group; 5 of 99 (5.05%) in in the Trident I PSL group and 8 of 193 (4.15%) in the Trident II group. Conclusions. Our observation of malseating in 5.6% of patients is clearly disconcerting. The etiology of malseating is unclear ranging from soft tissue interposition to possible shell deformation leading to a geometric mismatch between cup and liner. The clinical impact of this observation is unknown but speculation regarding risk of micromotion along the interface leading to fretting and corrosion appears plausible. Further clinical followup will be necessary to determine whether these radiographic finding will ultimately impact clinical outcome. For any tables or figures, please contact the authors directly