Introduction. Because of concerns regarding excessive wear and short-term failures attributed to the metal-on-metal bearings, the use of metal-on-metal hip resurfacing arthroplasty (MOMHRA) has been greatly reduced since 2008, despite great mid-term results for well-designed implants and in certain patient populations. The true cause of excessive wear was then unknown. Therefore, identification of true risk factors for the procedure became paramount to refine indications and improve survivorship outcomes. Methods. Over the last 10 years, a systematic search of the US national library of Medicine and National institutes of health with the key words “metal-on-metal” and hip resurfacing” was conducted and returned 2186 items. Of these items, 862 were deemed relevant to our research purposes and entered in our center's reference database from which this review was performed. Results. Edge loading is the main culprit for high wear and high serum Co and Cr ion concentrations because it disrupts the fluid film lubrication of the device. Computation of the contact patch to rim distance (CPR), an estimate of the joint's functional coverage, is the best predictor of potential edge loading and excessive wear. Both in vivo and in vitro studies show that the wear of well-designed and well-positioned MOM bearings diminishes over time with continued use, an advantage only featured by MOM bearings. Systemic wear-related complications and hypersensitivity to metal once thought to be common are in fact rare occurrences. In addition, metal-related revisions only represent a small portion of the various modes of failure encountered with well-designed HRA. In our series of 1321 hips with only 0.5% lost to follow-up, 11 patients underwent revision surgery for excessive wear or adverse local tissue reaction. All but 2 had mal-positioned acetabular components (CPR distance <10mm). One of these 2 patients had serum cobalt and chromium levels of 13 and 9 µg/L respectively, despite a CPR distance of 18.3 mm, while the other showed a peri-prosthetic fluid collection estimated at 111cc on MRI. Component aseptic loosening (acetabular or femoral) remains, as is also the case for total hip arthroplasty (THA), the leading indication for revision surgery, even though substantial progress has been reported to reduce its incidence. Femoral neck fractures and loosening are associated with the surgeon's learning curve which can be avoided with proper training. The survivorship of the femoral component in our series after implementation of surgical technique changes is 99.2% at 10 years for an overall survivorship of 95.5%. A diagnosis of DDH is associated with a higher failure rate, particularly from socket loosening, while women without risk factors have a survivorship of 98.6% at 15 years. Conclusion. HRA has often been, but should not be associated with the results of large head metal-on-metal THA which often present with a different set of failure mechanisms. Now that most of the risk factors for HRA have been identified, and solutions found, a balanced perspective of its results is needed because the long-term data available validate the low wear of MOM bearings which was predicted in the early hip simulator studies. Considering the tremendous progress made in surgical technique and the advanced tribological knowledge acquired with the last 20 years of investigations related to MOM HRA, all the conditions are present to make this procedure a success for lifetime durability as shown in our series where 44 patients (54 hips) have died without a revision at a mean follow-up time of 9.7 years (range, 1.8 to 19.7). For HRA, when devices with adequate coverage and clearance of the ball by the socket are used, severe developmental dysplasia and inadequate surgical technique are responsible for most failures at 10 to 15 years of follow-up. It is our opinion that the advantages of HRA over THA (such as absence of thigh pain, a low dislocation rate, no taper corrosion, and the preservation of proximal femoral bone mineral density and the ability to maintain high activity levels without penalty) now outweigh the risks of using a MOM bearing

Introduction. The direct anterior approach (DAA) for total hip arthroplasty (THA) has gained popularity in recent years. Potential advantages over other surgical approaches include less postoperative pain, fewer postoperative precautions, and quicker early recovery. It is most commonly performed in the supine position with traction tables or table mounted bone hooks to facilitate exposure. In this study, we describe a reproducible surgical technique for DAA THA in the lateral decubitus position with use of standard THA equipment and report on our results and learning curve. Methods. A prospectively collected hip repository was queried for all primary THA DAA performed in the lateral position by a single surgeon over a 4-year period from the surgeon's first case utilizing the technique. Retrospective chart review was performed to identify complications and revisions. Modified Harris Hip Score (mHHS) was collected pre-operatively and again at 1-year post-operative. Radiographic parameters including were measured on the 1-year postoperative radiographs. Results. Three hundred forty-one hips were identified in patients over 18 years of age with 337 hips meeting our inclusion/exclusion criteria. A total of 257 hips (76%) had a minimum of 1-year follow-up. 212 of 225 hips (94%) with available mHHS data achieved MCID, defined as mHHS change of > 8. Mean surgical time was 88 ± 16 minutes. Radiographic evaluation demonstrated reproducible results with mean radiographic side to side leg length discrepancy of 2.6 ± 5.9mm and femoral offset difference of 0.2 ± 4.9mm. Among patients with adequate postoperative radiographs, 234 of 243 (96%) had acetabular component positions within Lewinnick's safe zone. 3 hips (0.9%) required revision THA within the first year postoperatively. There were no dislocations and there was no learning curve detected in terms of operative time, blood loss, complication rate or acetabular component position. Discussion. Critics of DAA THA cite its long learning curve with increased risk of complications as an argument against its widespread use. In this study, we have described a safe and efficient technique for performing THA via the DAA in the familiar lateral decubitus with the use of a standard operating table, positioning devices and THA instrumentation. Our results demonstrate excellent acetabular component placement and low rates of complications within the first postoperative year. Conclusion. DAA THA can be performed safely and efficiently in the lateral decubitus position without a specialized table or instrumentation. Surgeon familiarity with patient position and instruments using the technique presented here may be associated with a shorter procedural learning curve

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

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures.

We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):54–9.

We have evaluated the results of total hip replacement in patients with congenital hip disease using 46 cemented all-polyethylene Charnley acetabular components implanted with the cotyloplasty technique in 34 patients (group A), and compared them with 47 metal-backed cementless acetabular components implanted without bone grafting in 33 patients (group B). Patients in group A were treated between 1988 and 1993 and those in group B between 1990 and 1995. The mean follow-up for group A was 16.6 years (12 to 18) and the mean follow-up for group B was 13.4 years (10 to 16).

Revision for aseptic loosening was undertaken in 15 hips (32.6%) in group A and in four hips (8.5%) in group B. When liner exchange was included, a total of 13 hips were revised in group B (27.7%). The mean polyethylene wear was 0.11 mm/yr (0.002 to 0.43) and 0.107 mm/yr (0 to 0.62) for groups A and B, respectively. Polyethylene wear in group A was associated with linear osteolysis, and in group B with expansile osteolysis.

In patients with congenital hip disease, when 80% cover of the implant can be obtained, a cementless acetabular component appears to be acceptable and provides durable fixation. However, because of the type of osteolysis arising with these devices, early exchange of a worn liner is recommended before extensive bone loss makes revision surgery more complicated.

Aims. Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies. Methods. Posterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment. Results. The force vector of the mallet strike, relative to the introducer axis, was misaligned by an average of 18.1°, resulting in an average wasted strike energy of 6.1%. Furthermore, the mean strike offset was 19.8 mm from the centre of the introducer axis and the mallet face, relative to the introducer strike face, was misaligned by a mean angle of 15.2° from the introducer strike face. Conclusion. The direction of the impact vector in manual impaction lacks both accuracy and precision. There is an opportunity to improve this through more advanced impaction instruments or surgical training. Cite this article: Bone Joint Res 2024;13(4):193–200

Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons. This is a single-centre, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture. Radiographic analysis was performed using validated software to measure femoral- (canal flare index [CFI], morphological cortical index [MCI], calcar-calcar ratio [CCR]) and pelvic- (Ilium-ischial ratio [IIR], ilium overhang, and ASIS to greater trochanter distance) morphologies and surgical technique (% canal fill). Multivariate and Receiver-Operator Curve (ROC) analysis was performed to identify predictors of fracture. Femoral factors that differed included CFI (3.7±0.6 vs 2.9±0.4, p<0.001) and CCR (0.5±0.1 vs 0.4±0.1, p=0.006). The mean IIR was higher in fracture cases (3.3±0.6 vs 3.0±0.5, p<0.001). % Canal fill was reduced in fracture cases (82.8±7.6 vs 86.7±6.8, p=0.007). Multivariate analysis and ROC analyses revealed a threshold CFI of 3.17 was predictive of fracture (sensitivity:84.6% / specificity:75.6%). Fracture risk was 29 times higher when patients had CFI>3.17 and II ratio>3 (OR:29.2 95%CI: 9.5–89.9, p<0.001). Patient-specific anatomical parameters are important predictors of fracture-risk. When considering the use of short stems via the AA, careful radiographic analysis would help identify those at risk in order to consider alternative stem options

Aims. The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union. Methods. We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union. Results. A total of 331 patients underwent PAO during the study period with 56 (15.4%) stress fractures: 46 fractures of the retroacetabular posterior column, five cases of ischiopubic stress fracture, and five cases of concurrent ischiopubic and retroacetabular stress fractures. Overall, 86% (48/56) healed without intervention. Univariate analysis revealed that stress fractures occurred more frequently in females (p = 0.040), older patients (mean age 27.6 years (SD 8.4) vs 23.8 (SD 9.0); p = 0.003), and most often with the use of the broad Mast chisel (28.5%; p < 0.001). Multivariable analysis revealed that increasing age (odds ratio (OR) 1.04; 95% CI 1.01 to 1.07; p = 0.028) and use of the broad Mast chisel (OR 5.1 (95% CI 1.3 to 19.0) compared to narrow Ganz chisel; p = 0.038) and surgeon (p = 0.043) were associated with increased risk of stress fracture. Patients with stress fractures were less likely to have healed osteotomies after one-year follow-up (76% vs 96%; p < 0.001). Conclusion. Stress fracture of the posterior column may be an under-recognized complication following PAO, and the rate may be influenced by surgical technique. Consideration should be given to using a narrow chisel during the ischial cut to reduce the risk of stress propagation through the posterior column. Cite this article: Bone Joint J 2022;104-B(9):1017–1024

Sequelae of Legg-Calve -Perthes disease (LCPD) and treatment of developmental dysplasia of the hip (DDH) can present a coxa breva or coxa magna deformity, sometimes associated with coxa vara. This unique deformity decreases the efficiency of the abductor mechanism, causing a Trendelenburg gait and hip pain, leg length discrepancy and leads to intra- and extra-articular impingement, and eventually osteoarthritis. Several surgical techniques have been advocated to treat this kind deformity, such as great trochanter transfer, relative femoral neck lengthening. We evaluated primary results of true femoral neck-lengthening osteotomy (TFNLO) in combination with periacetabular osteotomy (PAO) for treatment of Coxa Breva through surgical hip dislocation (SHD). Fourteen patients with Coxa Breva received true femoral neck lengthening osteotomy in combination of PAO through SHD between March 2020 and October 2023. Ten patients with minimum 1 year followed-up were retrospectively reviewed clinically and radiographically. Eight patients had Perthes disease, 2 had DDH received closed reduction and fixation during childhood. The mean age at surgery was 16 years (range, 12 to 31 years). Clinical findings, radiographic analyses including the change in horizontal femoral offset and the leg length discrepancy as well as complications were assessed. Horizontal femoral offset improved 19.5mm(6–28mm). Limb length increase 16.8mm(11–30mm). Mean HHS increased from 80.6(66–91) to 91.8(88–96). Complication: screw broken in 1(no need operation). Asymptomatic fibrous union of the great trochanter was found in 1. No infection and joint space narrow as well as nerve palsy happened. TFNLO combined with PAO can be effective for the treatment of patients with Coxa breva. But long term follow up is warranted

Mechanical failure due to dislocation, fracture and acetabular wear as well as persistence of infection are the main complications associated with the use of hip spacers in the treatment of periprosthetic joint infections (PJI). We have developed a novel, custom-made spacer as part of two-stage septic hip replacement and present the two- to five-year results after reimplantation. We prospectively examined a total of 73 patients over our study period in whom our new spacer technique was used. The technique includes a dual mobility inlay and a cemented straight stem in combination with antibiotic-loaded PMMA bone cement which allows full weight bearing meanwhile the interim period. The follow-up ranged between 24 and 60 months after reimplantation as second stage of a two-stage approach. The patients were contacted as part of the follow-up using a questionnaire concerning reoperation, reinfection as well as hip function by using the Harris Hip Score. 72 patients (98,6%) could be reimplanted, one patient is still using the spacer prothesis for 45 months because of excellent functional results with a Harris Hip Score of 95, nevertheless reimplantation is planned. The reinfection rate was less than 7% after reimplantation. The dislocation rate was 5%, and in total there was an overall complication rate of less than 10%. The Harris Hip Score was significantly improved. The ENDO spacer surgical technique is a promising option in the treatment of periprosthetic joint infections (PJI) for two-stage septic exchange with a low dislocation rate and good infection control after reimplantation. In addition, it enables early mobilization with the possibility of full weight-bearing in the interval between spacer implantation and reimplantation

Few surgical techniques to reconstruct the abductor mechanism of the hip have been reported, with outcomes reported only from case reports and small case series from the centres that described the techniques. As in many of our revision THA patients the gluteus maximus was affected by previous repeat posterior approaches, we opted to reconstruct the abductor mechanism using a vastus lateralis to gluteus medius transfer. We report the results of such reconstructions in seven patients, mean age 66 (range, 53–77), five females, presenting with severe abductor deficiency (MRC grade 1–2). Five patients had previous revision THA, two with a proximal femoral replacement, one patient had a primary THA after a failed malunited trochanteric fracture, and one patient had a native hip with idiopathic fatty infiltration of glutei of >90%. All patients had instrumented gait analysis, and surface electromyography (EMG) of the glutei, TFL, and vastus muscles simultaneously before surgery and at each post-op follow-up. Postoperatively, patients were allowed to weight bear as tolerated and were requested to wear an abduction brace for the first six weeks after surgery to protect the transfer. All patients improved after surgery and reached an abductor power of 3 or more. All patients walked without support six months after surgery and were satisfied with the result. Abductor function continued to improve beyond one year of follow-up, and some patients reached an abductor power of 5. EMG demonstrated that the transferred vastus lateralis started firing synchronously with gluteus medius after three months post-surgery, suggesting adaptation to its new function. No knee extension weakness was recorded. One patient complained of lateral thigh numbness and was dissatisfied with the cosmetic look of her thigh after surgery. Our preliminary results are encouraging and comparable with those achieved by the originators of the technique

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. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

Local anatomical abnormalities vary in congenital hip disease patients. Authors often present early to mid-term total hip arthroplasty clinical outcomes using different techniques and implants randomly on patients with different types of the disease, making same conclusions difficult. We report long term outcomes (13 to 23 years) of the treatment of low and high dislocation cases (separately) with total hip arthroplasty using TM technology acetabular cups (Implex initially and then Zimmer) and short fluted conical (Zimmer) femoral stems. From 2000 to 2010, 418 congenital hip disease hip joints were treated in our department with total hip arthroplasty. According to Hartofilakidis et al's classification, 230 hips had dysplasia, 101 low dislocation, (group A) and 87 high dislocation (group B). Pre-operative and post-operative values, at regular intervals, of HHS, SF-12, WOMAC, OHS and HOOS were available for all patients. Patient, surgeon and implant related failures and complications were recorded for all patients. In all cases an attempt was made to restore hip center of rotation. In group A the average lengthening was 2.8 cm (range: 1 to 4.2) and in group B 5.7 cm (range: 4.2 to 11). In both groups, no hips were revised due to aseptic loosening of either the acetabular cup or the femoral stem. In group A, a cumulative success rate of 95.6% (95% confidence interval, 92.7% – 97.4%) and in group B a cumulative success rate of 94.8% (95% confidence interval, 92.6%–96.9%) was recorded, at 20 years, with revision for any reason as an end point. No s.s. differences were found between groups when mean values of HHS, SF-12, WOMAC and OKS were compared. Satisfactory long-term clinical outcomes can be achieved in treating different types of congenital hip disease when appropriate surgical techniques combined with “game changing” implants are used

Revision total hip arthroplasty (rTHA) in the presence of femoral defects can be technically challenging. Reconstruction with long stems is widely accepted as the standard. However long stems can be difficult to insert and can compromise distal bone stock for future revisions. The aims of this study were to identify whether there was a difference in survival and outcomes following rTHA using a long versus standard or short femoral stem. A comprehensive systematic review was performed according to PRISMA guidelines using the MEDLINE, EMBASE, Chochrane Library and Web of Science databases. Inclusion criteria were (i) adult patients >18 years; (ii) randomised controlled trials, joint registry, or cohort studies; (iii) single or staged rTHA for Paprosky 1–3B femoral defects. Exclusion criteria were (i) mixed reporting without subgroup analysis for revision stem length; (ii) ex-vivo studies. Screening for eligibility and assessment of studies was performed by the authors. Out of 341 records, 9 studies met criteria for analysis (including 1 study utilising joint registry data and 1 randomised controlled trial). Across studies there were 3102 rTHAs performed in 2982 patients with a mean age of 67.4 years and a male: female ratio of 0.93. Revision prostheses were long-stemmed in 1727 cases and short or standard in 1375 cases with a mean follow up of 5 years (range, 0-15 years). On subgroup analysis the use of a long cemented stem compared to a long cementless prosthesis was associated with fewer complications and periprosthetic fracture in older patients. Survivorship was 95% with short stems compared to 84% with long stems at 5 years. Moderate quality evidence suggests that in rTHA with Paprosky type 1-3B femoral defects, the use of a short or standard stem can achieve comparable outcomes to long stems with fewer significant complications and revisions. Using a shorter stem may yield a more straightforward surgical technique and can preserve distal bone stock for future revision

Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF). This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel. Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA. This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique

The best treatment method of large acetabular bone defects at revision THR remains controversial. Some of the factors that need consideration are the amount of residual pelvic bone removed during revision; the contact area between the residual pelvic bone and the new implant; and the influence of the new acetabular construct on the centre of rotation of the hip. The purpose of this study was to compare these variables in two of the most used surgical techniques used to reconstruct severe acetabular defects: the trabecular metal acetabular revision system (TMARS) and a custom triflanged acetabular component (CTAC). Pre- and post-operative CT-scans were acquired from 11 patients who underwent revision THR with a TMARS construct for a Paprosky IIIB defect, 10 with pelvic discontinuity, at Royal Adelaide Hospital. The CT scans were used to generate computer models to virtually compare the TMARS and CTAC constructs using a semi-automated method. The TMARS construct model was calculated using postoperative CT scans while the CTAC constructs using the preoperative CT scans. The bone contact, centre of rotation, inclination, anteversion and reamed bone differences were calculated for both models. There was a significant difference in the mean amount of bone reamed for the TMARS reconstructions (15,997 mm. 3. ) compared to the CTAC reconstructions (2292 mm. 3. , p>0.01). There was no significant difference between overall implant bone contact (TMARS 5760mm. 2. vs CTAC 5447mm. 2. , p=0.63). However, there was a significant difference for both cancellous (TMARS 4966mm. 2. vs CTAC 2887mm. 2. , p=0.008) and cortical bone contact (TMARS 795mm. 2. vs CTAC 2560mm. 2. , p=0.001). There was no difference in inclination and anteversion achieved. TMARS constructs resulted on average in a centre of rotations 7.4mm more lateral and 4.0mm more posterior. Modelling of two different reconstructions of Paprosky IIIB defects demonstrated potential important differences between all variables investigated

The documentation of deep infection rates in joint replacement is fraught with multiple difficulties. Deep infections acquired in theatre may present late, but some later presenting deep infections are clearly haematogenous, and not related to surgical management. The effect of Ultra Clean Air on infection rates was published by Charnley in 1972 (CORR,87:167–187). The data is valuable because large numbers of THRs were performed in standard and Ultra Clean theatres, and detailed microbiology of the air was also recorded. No IV antibiotics were used, so only the effect of air quality was studied. We extracted the data on theatre type and numbers from Table 3, and numbers and intervals from surgery of deep infections from Table 7. Theatre types with 300 air changes per hour and 3.5 CFU/M. 3. were classified as Ultra Clean. A logistic regression model was used to examine the effect of theatre type and time elapsed after procedure on the probability of becoming infected. The model suggests that, controlling for time period, Ultra Clean Air is associated with a significantly lower probability of infection, with an OR of 0.30, p = 2.74 × 10. −6. The effect is larger earlier post-surgery, but it does persist. The results are best reviewed as a graphic, which shows that Ultra Clean Air clearly affects the deep infection rate for up to four years post-surgery. Ultra Clean Air reduces infection rates for up to four years post-surgery, so it is safe to assume that infections presenting after this are haematogenous. Ultra Clean Air does not eliminate early deep infection, so some early infections are not related to air quality. It is not practical to undertake widespread detailed retrospective analyses of cases. When monitoring infection rates there needs to be a balance between failing to record infections related to surgical technique and waiting many years to record low numbers of very late presenting problems. We suggest that registries should regard infections documented within three years of surgery as treatment complications. For any figures or tables, please contact the authors directly

Aims. In elderly patients with osteoarthritis and protrusio who require arthroplasty, dislocation of the hip is difficult due to migration of the femoral head. Traditionally, neck osteotomy is performed in situ, so this is not always achieved. Therefore, the purpose of this study is to describe a partial resection of the posterior wall in severe protrusio. Methods. This is a descriptive observational study, which describes the surgical technique of the partial resection of the posterior wall during hip arthroplasty in patients with severe acetabular protrusio operated on between January 2007 and February 2017. Results. In all, 49 hip arthroplasties were performed. The average age of patients was 60 years, and idiopathic was the most frequent aetiology of protrusio. All patients were treated with femoral head autograft and no intra- or postoperative complications were reported. No patients required revision surgery. Conclusion. Partial resection of the posterior wall demonstrated to be a safe surgical technique with 100% survival in a follow-up to ten years in total hip arthroplasty due to severe acetabular protrusio. Cite this article: Bone Joint Open 2020;1-7:431–437

Detection of clinical situations are the most difficult for primary THA and factors which determine the complexity. Results of 2368 primary THA performed by one surgeon in 1923 patients with various hip pathologies from 2004 to 2016 were analyzed. The time of the surgery, the bloodloss, the features of the surgical technique, the implants used, and the incidence of complications and revisions were assessed and X-ray analysis was performed. Difficult cases of primary hip arthroplasty include severe dysplasia (types B2, C1, and C2 according to the Hartofilakidis classification), post-traumatic segmental acetabular defects and pelvic discontinuity, protrusio acetabuli, iatrogenic bone ankylosis and consequences of proximal femur fractures with significant shortening of the limb. X-ray signs of difficulty included an interruption of the Shenton line of 2 cm or more (except for acute fractures of proximal femur), the femoral neck-shaft angle less than 100°, and the horizontal distance from Kohler line to center of rotation less than 20% of the diameter of the femoral head. An additional burdening factor is the previous surgical interventions on the hip joint. The ten-year survival rate for standard cases was 94.9%, and for complex cases − 92.3%. The odds ratio development of complications in complex cases compared to standard cases is OR = 8.402 (95% CI from 4.614 to 15.300). In standard cases mean HHS increased from 42.9 points before surgery to 95.3 after surgery. In complex cases mean HHS before surgery was 38.9 and after surgery improved to 81.6 points, p <0.001. The complexity of the operation cannot be determined on the basis of only the etiological factor, it is necessary to take into account the severity of anatomical changes