Eliminating pain and restoring physical activity are the main goals of total hip arthroplasty (THA). Despite the high relevance of activity as a rehabilitation goal of and criterion for discharge, in-hospital activity between operation and discharge has hardly been investigated in orthopaedic patients. Therefore, the aim of this study was to a) measure for reference the level of in-hospital physical activity in patient undergoing a current rapid discharge protocol, b) compare these values to a conventional discharge protocol and c) test correlations with pre-operative activities and self-reported outcomes for possible predictors for rapid recovery and discharge. Patients (n=19, M:F: 5:14, age 65 ±5.7 years) with osteoarthritis treated with an elective primary THA underwent a rapid recovery protocol with discharge on day 3 after surgery (day 0). Physical activity was measured using a 3D accelerometer (64×25×13mm, 18g) worn on laterally on the unaffected upper leg. The signal was analysed using self-developed, validated algorithms (Matlab) calculating: Time on Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min), walking bouts, longest walk (steps). For the in-hospital period (am: ca. 8–13h; pm: ca. 13–20h) activity was calculated for day 1 (D1) and 2 (D2). Pre-operative activity at home was reported as the daily averages of a 4-day period. Patient self-report included the HOOS, SQUASH (activity) and Forgotten Joint Score (FJS) questionnaires. In-hospital activity of this protocol was compared to previously collected data of an older (2011), standard conventional discharge protocol (day 4/5, n=40, age 71 ±7 years, M:F 16:24). All activity parameters increased continuously between in-hospital days and subsequent am and pm periods. E.g. Time-on-feet increased most steeply and tripled from 21.6 ±14.4min at D1am to 62.6 ±33.4min at D2pm. Mean Steps increased almost as steep from 252 to 655 respectively. SST doubled from 4.9 to 10.5. All these values were sign. higher (+63 to 649%) than the conventional protocol data. Cadence as a qualitative measure only increased slowly (+22%) (34.8 to 42.3steps/min) equalling conventional protocol values. The longest walking bout did not increase during the in-hospital period. Gender, age and BMI had no influence on in-hospital activity. High pre-op activity (ToF, steps) was a predictor for high in-hospital activity for steps and SST's at D2pm (R=0.508 to R=0.723). Pre-op self-report was no predictor for any activity parameter. In-hospital recovery of activity is steep following a cascade of easy (ToF) to demanding (SST) tasks to quality (cadence). High standard deviations show that recovering activity is highly individual possibly demanding personalised support or goals (feedback). Quantitative parameters were all higher in the rapid versus the conventional discharge protocol indicating that fast activation is possible and safe. Equal cadence for both protocols shows that functional capacity cannot be easily accelerated. Pre-op activity is only a weak predictor of in-hospital recovery, indicating that surgical trauma affects patients similarly, but subjects may be identified for personalized physiotherapy or faster discharge. Reference values and correlations from this study can be used to optimize or shorten in-hospital rehabilitation via personalization, pre-hab, fast-track surgery or biofeedback

Introduction: Physical activity is a major outcome in total hip arthroplasty (THA) and discharge criterion. Increasing immediate post-op activity may accelerate discharge, enable fast track surgery and improve general rehabilitation. Preliminary evidence (O'Halloran P.D. et al. 2015) shows that feedback via motivational interviewing can result in clinically meaningful improvements of physical activity. It was the aim of this study to use wearable sensor activity monitors to provide and study the effect of biofeedback on THA patients' activity levels. It was hypothesized that biofeedback would increase in-hospital and post-discharge activity versus controls. Methods: In this pilot study, 18 patients with osteoarthritis receiving elective primary THA followed by a rapid recovery protocol with discharge on day 3 after surgery (day 0) were randomized to the feedback group (n=9, M/F: 4:5, age 63.3 ± 5.9 years, BMI 26.9 ± 5.1) or a non-feedback control group (n=9, M/F: 0:9, age 66.9 ± 5.1 years, BMI 27.1 ± 4.0). Physical activity was measured using a wearable sensor and parameters (Time-on-Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min)) were calculated using a previously validated algorithms (Matlab). For the in-hospital period data was calculated twice daily (am, ca. 8–13:00h and pm, ca. 13–20:00h) of day 1 (D1) and 2 (D2). The feedback group had parameters reported back twice (morning, lunch) using bar charts comparing visually and numerically their values (without motivational instructions) to a previously measured reference group (n=40, age 71 ±7 years, M:F 16:24) of a conventional discharge protocol (day 4/5). Activity measures continued from discharge (D3) until day 5 (D5) at home. Results: Randomization resulted in matched groups regarding age and BMI, but not gender. The first post-op activity assessment (D1am) was identical between groups. Also thereafter similar values with no significant differences in any parameter were seen, e.g. the time-on-feet at D2PM was 59.2 ±31.7min (feedback) versus 62.9 ±39.2min (controls). Also on the day of discharge and beyond, no effect from the in-hospital feedback was measured. For both groups the course of activity recovery showed a distinct drop on day 4 following a highly active day of discharge (D3). On day 5, activity levels only recovered partially. For both groups, all quantitative activity parameters were significantly higher than the reference values used for feedback. Only cadence as a qualitative measure was the same like reference values. Discussion: Biofeedback using activity values from a body-worn monitor did not increase in-hospital or immediate post-op home activity levels compared to a control group when using the investigated feedback protocol. In general, while the day of discharge steeply boosts patient activity, the day after at home results in an activity drop to near in-patient levels before discharge. In a fast track surgery protocol, it may be of value to avoid this drop via patient education or home physiotherapy. Biofeedback using activity monitors to increase immediate post-op activity for fast track surgery or improved recovery may only be effective when feedback goals are set higher, are personalised or have additional motivational context

Introduction. The goal of joint-preserving surgery for the treatment of osteonecrosis of the femoral head (ONFH) is to delay or prevent osteoarthritic development. Bone marrow is a source of osteogenic progenitors that are key elements in the process of bone formation and fracture healing. We established an easy-to-use method using a conventional manual blood bag centrifugation technique traditionally used for extracting buffy coats, for concentration of nucleated cells and platelets from clinical bone marrow aspirates to obtain osteogenic progenitors and growth factors. However, it is unclear whether the surgical goals are really achieved and if so in which patients. The purpose of this study was to identify demographic, clinical, and radiographic factors predicting total hip arthroplasty (THA) conversion after CABMAT for the treatment of idiopathic ONFH. Methods. We retrospectively reviewed 123 patients (213 hips) who had CABMAT between 2003 and 2010. Sixty-five subjects (115 hips) were male and 58 (98 hips) were female with an average age at the time of CABMAT of 40.1 years. Of the 213 hips, 143 hips in 78 patients had corticosteroid-induced ONFH, 46 hips in 27 patients had alcohol-associated, and 24 hips in 18 patients had no etiological factors could be detected. The mean follow-up period was 60.5 months. The endpoint of evaluation was set as the time point which the patient required additional surgery (THA) depending on the spontaneous hip pain, x-ray change, and social back ground. The following factors were investigated: age, sex, body mass index (BMI), unilateral or bilateral, etiological factors, preoperative classification and staging, visual analogue scale (VAS), JOA clinical score. The 213 hips were divided into two groups: a THA conversion (THA) group and a non-THA conversion (non-THA) group. A multivariate analysis was performed using a logistic regression model. Results. In this series, of the 213 hips, 51 hips (23.9%) in 37 patients converted THA. The mean age of patients in THA group was 43.0 years and that of non-THA group was 39.2 years. The mean duration between CABMAT and THA conversion was 26.9 months. Preoperatively, 11 of the 213 hips were classified as type A, 8 hips as type B, 78 hips as type C1, and 116 hips as type C2. 48 hips were classified as stage 1, 65 hips as stage 2, 58 as Stage 3A, 34 as Stage 3B, 8 as stage 4. Postoperatively, no hips in types A and B, 11 hips (14.1%) in type C1, 40 hips (34.5%) in type C2, and 8 hips (16.7%) in stage 1, 13 hips (25.0%) in stage 2, 14 hips (24.1%) in stage 3A, 11 hips (32.4%) in stage 3B, 5 hips (62.5%) in stage 4 were converted THA. Conclusions. The strongest predictors of THA conversion after CABMAT were type, the extent of necrotic area, and age. The results suggest that what factors determine the THA conversion after CABMAT and which patients of idiopathic ONFH are appropriate for CABMAT treatment. Further careful follow-up is needed clinically, and an additional treatment strategy to improve CABMAT is currently in progress

Patients with Paget's Disease of Bone (PDB) more frequently require total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, controversy remains regarding their outcome. This project aims to evaluate the current literature regarding outcomes following THA and TKA in PDB patients. MEDLINE, EMBASE and Cochrane databases were searched on February 15th, 2022. Inclusion criteria comprised studies evaluating outcomes following THA/TKA in PDB patients. Quality of included studies was assessed using the Newcastle-Ottawa Scale. 19 articles (published between 1976–2022) were included, comprising 58,695 patients (48,766 controls and 10,018 PDB patients), from 209 potentially relevant titles. No study was of high quality. PDB patient pooled mortality was 32.5% at mean 7.8(0.1-20) years following THA and 31.0% at mean 8.5(2-20) years following TKA. PDB patient revision rate was 4.4% at mean 7.2(0-20) years following THA and 2.2% at mean 7.4(2-20) years following TKA. Renal complications, respiratory complications, heterotopic ossification, and surgical site infection were the most common medical and surgical complications. The largest systematic review, to date, evaluating outcomes following THA and TKA in PDB patients. All functional outcome scores improved. PDB patient revision rate was comparable to UK National Joint Registry. However, there is a significant need for prospective matched case-control studies to robustly compare outcomes in PDB patients with unaffected counterparts

Elective orthopaedic procedures, and particularly total hip arthroplasty (THA), in octogenarians and nonagenarians patients are burdened of several implications. Besides the comorbidities and the anesthesiological issues, legal and ethical implications are present. Some literature data show the clinical improvement of THA in elderly patient but the psychological aspects are not yet evaluated. Aim of this study is to evaluate the clinical aspects and the psychological impact in daily living in octogenarians and nonagenarians patients addressing THA. We conducted a retrospective evaluation of 81 THA in 81 patients of age more than 85 years with a minimum follow-up of 6 months. Clinical aspects were evaluated using the Hip disability and Osteoarthritis Outcome Score (HOOS). The psychological issues were evaluated with the Short Form 12 (SF-12) using both the Physical Component Summary (PCS) and the Mental Component Summary (MCS). From the starter cohort of 81 patients, 8 patients were died for causes unrelated to surgery, 13 were lost to follow-up, 1 patient was revised for periprosthetic fracture; 59 patients composed the final cohort. Mean HOOS rased from 18,07 ± 17,81 to 92,36 ± 5,74 with statistically significant distribution both in the global score than in all of the different subscales. The PCS raised from 26,81 ± 10,81 to 51,86 ± 4,45 and The MCS raised from 34,84 ± 10,81 to 56,70 ± 5,04, but none of them showed a statistically significant distribution. THA in octogenarians and nonagenarians patients could be a safe procedure with positive results for clinical and psychological aspects

This study compared the pullout forces of the initial implantation and the “cement-in-cement” revision technique for short and standard-length (125 mm vs. 150 mm) Exeter. ®. V40 femoral stems used in total hip arthroplasty (THA). The idea that the pullout force for a double taper slip stem is relative to the force applied to the femur and that “cement-in-cement” revision provides the same reproduction of force. A total sample size of 15 femoral stems were tested (Short, n = 6 and Standard, n = 9). 3D printed fixtures for repeatable sample preparation were used to minimize variance during testing. To promote stem subsidence and to simulate an in vivo environment, the samples were placed in an incubator at 37°C at 100% humidity and experienced a constant compressive loading of 1335 N for 14 days. The samples underwent a displacement-controlled pullout test. After the initial pullout test, “cement-in-cement” revision will be performed and tested similar to the initial implantation to observe the efficacy of the revision technique. To compare the pullout forces between the two groups, a Kruskal-Wallis test using a significance level of 0.05 was conducted. The mean maximum pullout force for the short and standard-length femoral stems were 3939 ± 1178 N and 5078 ± 1168 N, respectively. The Kruskal-Wallis test determined no statistically significant difference between the two groups for the initial implantation (p = 0.13). The “cement-in-cement” revision pullout force will be conducted in future testing. This study demonstrated the potential use of short stem designs for THA as it provides similar levels of fixation as the standard-length femoral stem. The potential benefits for using a short stem design would be providing similar load transfer to the proximal femur, preserving proximal metaphyseal femoral bone in primary replacement, and reducing the invasiveness during revision

Introduction. The most frequent diagnosis in young adults undergoing total hip arthroplasty (THA) is osteonecrosis of the femoral head (ONFH), an evolving and disabling condition with an increasing prevalence worldwide. Treatment of ONFH remains a challenge mainly because of a lack of understanding of the disease's pathophysiological basis. This study investigated the biological processes that could be affected by ONFH by comparing the microstructure, histological characteristics and transcriptomic profile of trabecular bone from the femoral head (FH) and the intertrochanteric region (IT) of patients suffering from this condition. Method. A total of 18 patients with idiopathic ONFH undergoing THA in our institution were included. Trabecular bone explants were taken intraoperatively from the FH and the IT of patients. Bone microstructure was examined by micro-computed tomography (micro-CT). After bone sectioning, histological features were studied by hematoxylin and eosin staining. Differential gene expression was investigated using a microarray platform. Result. Micro-CT imaging showed higher trabecular separation and lower trabecular thickness and bone volume in trabecular bone from the FH than from the IT. Histological staining revealed that the number of osteoblasts on the bone surface and the percentage of empty lacunae were higher in trabecular bone from the FH. Transcriptome analysis identified a differential signature in trabecular bone from the FH compared to the IT. The gene ontology analyses of the genes overexpressed in trabecular bone from the FH revealed a range of enriched biological processes related to cell division and immune response. In contrast, most downregulated transcripts were involved in bone formation. Conclusion. This study identified changes in the microarchitecture, histological features and transcriptomic signature of trabecular bone from the FH of patients with idiopathic ONFH, which might underlie the pathophysiology of this condition. This work was supported by PI22/00939 grant from ISCIII-FEDER-MICINN-AES and Luis Alvarez grant from IdiPAZ

Introduction. A recent study to identify clinically meaningful benchmarks for gait improvement after total hip replacement (THA) has shown that the minimum clinically important improvement (MCII) in gait speed after THA is 0.32 m/sec. Currently, it remains to be investigated what preoperative factors link to suboptimal recovery of gait function after THA. This study aimed to identify preoperative lower-limb muscle predictors for gait speed improvement after THA for hip osteoarthritis. Method. This study enrolled 58 patients who underwent unilateral primary THA. Gait speed improvement was evaluated as the subtraction of preoperative speed from postoperative speed at 6 months after THA. Preoperative muscle composition of the glutei medius and minimus (Gmed+min) and the gluteus maximus (Gmax) was evaluated on a single axial computed tomography slice at the bottom end of the sacroiliac joint. Cross-sectional area ratio of individual composition to the total muscle was calculated. Result. The females (n=45) showed smaller total cross-sectional areas of the gluteal muscles than the males (n=13). Gmax in the females showed lower lean muscle mass area (LMM) and higher ratios of the intramuscular fat area and the intramuscular adipose tissue area to the total muscle area (TM) than that in the males. Regression analysis revealed that LMM/TM of Gmed+min may correlate negatively with postoperative improvement in gait speed. Receiver operating characteristic curve analysis for prediction of MCII in gait speed at ≥ 0.32 m/sec resulted in the highest area under the curve for Gmax TM with negative correlation. The explanatory variables of hip abductor muscle composition predicted gait speed improvement after THA more precisely in the females compared with the total group of both sexes. Conclusion. Preoperative Gmax TM could predict gait speed MCII after THA. Preoperative muscle composition should be evaluated separately based on sexes for achievement of clinically important improvement in gait speed after THA

Intraoperative fractures although rare are one of the complications known to occur while performing a total hip arthroplasty (THA). However, due to lower incidence rates there is currently a gap in this area of literature that systematically reviews this important issue of complications associated with THA. Method: We looked into Electronic databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), the archives of meetings of orthopaedic associations and the bibliographies of included articles and asked experts to identify prospective studies, published in any language that evaluated intra-operative fractures occurring during total hip arthroplasty from the year 1950-2020. The screening, data extraction and quality assessment were carried out by two researchers and if there was any discrepancy, a third reviewer was involved. Fourteen studies were identified. The reported range of occurrence of fracture while performing hip replacement surgery was found to be 0.4-7.6%. Major risk factors identified were surgical approaches, Elderly age, less Metaphyseal-Diaphyseal Index score, change in resistance while insertion of the femur implants, inexperienced surgeons, uncemented femoral components, use of monoblock elliptical components, implantation of the acetabular components, patients with ankylosing spondylitis, female gender, uncemented stems in patients with abnormal proximal femoral anatomy and with cortices, different stem designs, heterogeneous fracture patterns and toothed design. Intraoperative fractures during THA were managed with cerclage wire, femoral revision, intramedullary nail and cerclage wires, use of internal fixation plates and screws for management of intra operative femur and acetabular fractures. The main reason for intraoperative fracture was found to be usage of cementless implants but planning and timely recognition of risk factors and evaluating them is important in management of intraoperative fractures. Adequate surgical site exposure is critical especially during dislocation of hip, reaming of acetabulum, impaction of implant and preparing the femoral canal for stem insertion. Eccentric and increased reaming of acetabulum to accommodate a larger cup is to be avoided, especially in females and elderly patients as the acetabulum is thinner. However, this area requires more research in order to obtain more evidence on effectiveness, safety and management of intraoperative fractures during THA

Introduction. Cephalomedullary nailing (CMN) is commonly used for unstable pertrochanteric fracture. CMN is relatively safe method although various complications can potentially occur needing revision surgery. Commonly used salvage procedures such as renailing, hemiarthroplasty, conservative treatment or total hip arthroplasty (THA) are viable alternatives. The aim was to investigate the rate of THA after CMN and evaluate the performance on conversion total hip arthroplasty (cTHA) after failure of CMN. Method. Collected data included patients from two orthopedic centers. Data consisted of all cTHAs after CMN between 2014-2020 and primary cementless THA operations between 2013-2023. Primary THA operations were treated as a control group where Oxford Hip Score (OHS) was the main compared variable. Result. From 2398 proximal femoral hip procedures 1667 CMN procedures were included. Altogether 46/1667 (2.8%) CMNs later received THA. Indications for THA after CMN failure were 13 (28.3%) cut-outs, nine (19.6%) cut-throughs, eight (17.4%) nail breakages, seven (15.2%) post traumatic arthrosis, seven (15.2%) nonunions, one (2.2%) malunion and one (2.2%) collum screw withdrawal. Mean (SD) time to complication after CMN operation is 5.9 (6.8) months. Mean (SD) time from nail procedure to THA was 10.4 (12.0) months. Total complication rate for cTHA after CMN was 17.4%. Reported complications were infection with seven (15.2%) cases and one (2.2%) nerve damage. Mean (SD) time to cTHA complication was 3.6 (6.1) months. One-sample T-test showed OHS to be significantly better (P<.001) for primary cementless THA compared to cTHA after one year. Conclusion. Altogether 2.8% of CMN were converted to THA. Nearly half (47.8%) of the cTHA procedures were due to CMN cut-out or cut-through. OHS was significantly better in primary cementless THA compared to cTHA. Prosthetic joint infection was the most frequent complication related to cTHA

Total hip arthroplasty (THA) outcome in patients with osteonecrosis of the femoral head ONFH) are excellent, however, there is controversy when compared with those in patients with osteoarthritis (OA). Reduced mineralization capacity of osteoblasts of the proximal femur in patients with ONFH could affect implant fixation. We asked if THA fixation in patients with ONFH is worse than in those with OA. We carried out a prospective comparative case (OA)-control (ONFH) study of patients undergoing THA at our hospital between 2017 and 2019. The minimum follow-up was 2 years. Inclusion criteria were patients with uncemented THA, younger than 70 years old, a Dorr femoral type C and idiopathic ONFH. We compared the clinical (Merlé D'Aubigné-Postel score) and radiological results related with implant positioning and fixation. Engh criteria and subsidence were assessed at the immediate postoperative, 12 weeks, 6 months, 12 months and yearly. Osteoblastic activity was determined by mineralization assay on primary cultures of osteoblasts isolated from trabecular bone samples collected from the intertrochanteric area obtained during surgery. Group 1 (ONFH) included 18 patients and group 2 (OA), 22. Average age was 55.9 years old in group 1 and 61.3 in group 2. (p=0.08). There were no differences related with sex, Dorr femoral type or femoral filling. The mean clinical outcome score was 17.1 in group 1 and 16.5 in group 2 (p=0.03). There were no cases of dislocation, infection, or revision surgery in this series. There were 5 cases (28%) of femoral stem subsidence greater than 3mm within 6 first months in group 1 and 1 case (4.5%) in group 2 (p=0.05). Although there were no significant differences related to clinical results, bone fixation was slower, and a greater subsidence was observed in patients with ONFH. Greater femoral stem subsidence was associated with a lower capacity for mineral nodule formation in cultured osteoblasts. The surgical technique could influence THA outcome in patients with reduced mineralization capacity of osteoblasts

Results in patients undergoing total hip arthroplasty (THA) for femoral head osteonecrosis (ON) when compared with primary osteoarthritis (OA) are controversial. Different factors like age, THA type or surgical technique may affect outcome. We hypothesized that patients with ON had an increased revision rate compared with OA. We analysed clinical outcome, estimated the survival rate for revision surgery, and their possible risk factors, in two groups of patients. In this retrospective cohort analysis of our prospective database, we assessed 2464 primary THAs implanted between 1989 and 2017. Patients with OA were included in group 1, 2090 hips; and patients with ON in group 2, 374 hips. In group 2 there were more men (p<0.001), patients younger than 60 years old (p<0.001) and with greater physical activity (p<0.001). Patients with lumbar OA (p<0.001) and a radiological acetabular shape type B according to Dorr (p<0.001) were more frequent in group 1. Clinical outcome was assessed according to the Harris Hip Score and radiological analysis included postoperative acetabular and femoral component position and hip reconstruction. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having revision surgery for different reasons. Univariate and multivariate Cox regression models were used to assess risk factors for revision surgery. Clinical improvement was better in the ON at all intervals. There were 90 hips revised, 68 due to loosening or wear, 52 (2.5%) in group 1, and 16 (4.3%) in group 2. Overall, the survival rate for revision surgery for any cause at 22 years was 88.0 % (95% CI, 82-94) in group 1 and 84.1% (95% CI, 69 – 99) in group 2 (p=0.019). Multivariate regression analysis showed that hips with conventional polyethylene (PE), compared with highly-cross linked PEs or ceramic-on-ceramic bearings, (p=0.01, Hazard Ratio (HR): 2.12, 95% CI 1.15-3.92), and cups outside the Lewinnek´s safe zone had a higher risk for revision surgery (p<0.001, HR: 2.57, 95% CI 1.69-3.91). Modern highly-cross linked PEs and ceramic-on-ceramic bearings use, and a proper surgical technique improved revision rate in patients undergoing THA due to ON compared with OA

Pelvic tilt can vary over time due to aging and the possible appearance of sagittal spine disorders. Cup position in total hip arthroplasty (THA) can be influenced due to these changes. We assessed the evolution of pelvic tilt and cup position after THA and the possible appearance of complications for a minimum follow-up of ten years. 343 patients received a THA between 2006 and 2009. All were diagnosed with primary osteoarthritis and their mean age was 63.3 years (range, 56 to 80). 168 were women and 175 men. 250 had no significant lumbar pathology, 76 had significant lumbar pathology and 16 had lumbar fusion. Radiological analysis included sacro-femoral-pubic (SFP), acetabular abduction (AA) and anteversion cup (AV) angles. Measurements were done pre-operatively and at 6 weeks, and at five and ten years post-operatively. Three measurements were recorded and the mean obtained at all intervals. All radiographs were evaluated by the same author, who was not involved in the surgery. There were nine dislocations: six were solved with closed reduction, and three required cup revision. All the mean angles changed over time; the SFP angle from 59.2º to 60º (p=0.249), the AA angle from 44.5º to 46.8º (p=0.218), and the AV angle from 14.7º to 16.2º (p=0.002). The SFP angle was lower in older patients at all intervals (p<0.001). The SFP angle changed from 63.8 to 60.4º in women and from 59.4º to 59.3º in men, from 58.6º to 59.6º (p=0.012). The SFP angle changed from 62.7º to 60.9º in patients without lumbar pathology, from 58.6º to 57.4º in patients with lumbar pathology, and from 57.0º to 56.4º in patients with a lumbar fusion (p=0.919). The SFP cup angle was higher in patients without lumbar pathology than in the other groups (p<0.001), however, it changed more than in patients with lumbar pathology or fusion at ten years after THA (p=0.04). Posterior pelvic tilt changed with aging, influencing the cup position in patients after a THA. Changes due to lumbar pathology could influence the appearance of complications long-term

Pelvic bone defect in patients with severe congenital dysplasia of the hip (CDH) lead to abnormalities in lumbar spine and lower limb alignment that can determine total hip arthroplasty (THA) patients' outcome. These variables may be different in uni- or bilateral CDH. We compared the clinical outcome and the spinopelvic and lower limb radiological changes over time in patients undergoing THA due to uni- or bilateral CHD at a minimum follow-up of five years. Sixty-four patients (77 hips) undergoing THA due to severe CDH between 2006 and 2015 were analyzed: Group 1 consisted of 51 patients with unilateral CDH, and group 2, 113 patients (26 hips) with bilateral CDH. There were 32 females in group 1 and 18 in group 2 (p=0.6). The mean age was 41.6 years in group 1 and 53.6 in group 2 (p<0.001). We compared the hip, spine and knee clinical outcomes. The radiological analysis included the postoperative hip reconstruction, and the evolution of the coronal and sagittal spinopelvic parameters assessing the pelvic obliquity (PO) and the sacro-femoro-pubic (SFP) angles, and the knee mechanical axis evaluating the tibio-femoral angle (TFA). At latest follow-up, the mean Harris Hip Score was 88.6 in group 1 and 90.7 in group 2 (p=0.025). Postoperative leg length discrepancy of more than 5 mm was more frequent in group 1 (p=0.028). Postoperative lumbar back pain was reported in 23.4% of the cases and knee pain in 20.8%, however, there were no differences between groups. One supracondylar femoral osteotomy and one total knee arthroplasty were required. The radiological reconstruction of the hip was similar in both groups. The PO angle improved more in group 1 (p=0.01) from the preoperative to 6-weeks postoperative and was constant at 5 years. The SFP angle improved in both groups but there were no differences between groups (p=0.5). 30 patients in group 1 showed a TFA less than 10º and 17 in group 2 (p=0.7). Although the clinical outcome was better in terms of hip function in patients with bilateral CDH than those with unilateral CDH, the improvement in low back and knee pain was similar. Patients with unilateral dysplasia showed a better correction of the PO after THA. All spinopelvic and knee alignment parameters were corrected and maintained over time in most cases five years after THA

Arthroscopic management of femoroacetabular impingement (FAI) has become the mainstay of treatment. However, chondral lesions are frequently encountered and have become a determinant of less favourable outcomes following arthroscopic intervention. The aim of this systematic review and meta-analysis was to assess the outcomes of hip arthroscopy (HA) in patients with FAI and concomitant chondral lesions classified as per Outerbridge. A systematic search was performed using the PRISMA guidelines on four databases including MEDLINE, EMBASE, Cochrane Library and Web of Science. Studies which included HA as the primary intervention for management of FAI and classified chondral lesions according to the Outerbridge classification were included. Patients treated with open procedures, for osteonecrosis, Legg-Calve-Perthes disease, and previous ipsilateral hip fractures were excluded. From a total of 863 articles, twenty-four were included for final analysis. Demographic data, PROMs, and radiological outcomes and rates of conversion to total hip arthroplasty (THA) were collected. Risk of bias was assessed using ROBINS-I. Improved post-operative PROMs included mHHS (mean difference:-2.42; 95%CI:-2.99 to −1.85; p<0.001), NAHS (mean difference:-1.73; 95%CI: −2.23 to −1.23; p<0.001), VAS (mean difference: 2.03; 95%CI: 0.93-3.13; p<0.001). Pooled rate of revision surgery was 10% (95%CI: 7%-14%). Most of this included conversion to THA, with a 7% pooled rate (95%CI: 4%-11%). Patients had worse PROMs if they underwent HA with labral debridement (p=0.015), had Outerbridge 3 and 4 lesions (p=0.012), concomitant lesions of the femoral head and acetabulum lesions (p=0.029). Reconstructive cartilage techniques were superior to microfracture (p=0.042). Even in concomitant lesions of the femoral head and acetabulum, employing either microfracture or cartilage repair/reconstruction provided a benefit in PROMs (p=0.027). Acceptable post-operative outcomes following HA with labral repair/reconstruction and cartilage repair in patients with FAI and concomitant moderate-to-severe chondral lesions, can be achieved. Patients suffering from Outerbridge 3 and 4 lesions, concomitant acetabular rim and femoral head chondral lesions that underwent HA with labral debridement, had worse PROMs. Reconstructive cartilage techniques were superior to microfracture. Even in concomitant acetabular and femoral head chondral lesions, employing either microfracture or cartilage repair/reconstruction was deemed to provide a benefit in PROMs

Abstract. Objective. Short-stem total hip arthroplasty (THA) aims to preserve the proximal bone stock for future revisions, so that the first revision should resemble a primary intervention rather than a revision. This study aimed to compare the clinical and radiological outcomes in revision THA after failed short stem versus after failed conventional stem THA. Methods. This study included forty-five patients with revision THA divided into three groups (15 each); group A: revision after short stem, group B: revision after conventional cementless stem and group C revision after conventional cemented stem. The studied groups were compared regarding 31 variables including demographic data, details of the primary and revision procedures, postoperative radiological subsidence, hospital stay, time for full weight bearing (FWB), preoperative and postoperative clinical scores. Results. Early stem subsidence (40%) was the main indication of revision in group A compared to peri-prosthetic femoral fractures (PFFs) (73.3%) and aseptic loosening (53.3%) in group B and C respectively (P=0.021). The mean time to revision was significantly shorter in group A (15 months) compared to 95.33 and 189.40 months in group B and C respectively. (P=0.005). Sixty % (9 patients) in group A were revised in the first year. The mean operative time, blood loss, postoperative blood transfusion and hospital stay were significantly lower in group A compared to group B and C (P<0.001, <0.001, 0.002 and 0.001 respectively). Revisions in group A were performed using either short stems (13.3%) or conventional stems (86.7%) whilst 80% of patients needed long stems and 20% of patients needed conventional stems in group B and C (P<0.001). The mean postoperative Harris Hip Score (HHS) at the latest follow up was 87.07, 87.53 and 85.47 in group A, B and C respectively. All PFFS had excellent results according to Beal's and Tower's criteria; all fractures healed and the implants were stable. Conclusion. The most common cause of failure of short stems is early stem subsidence. Short stem THA has specific indications and patient selection is very crucial. Preoperative templating for short stems and a detailed analysis of the individual patient anatomy in anteroposterior and lateral views are mandatory to predict the correct implant size more accurately. The use of intraoperative imaging can verify the sizing, implant position, and sufficient contact with the lateral cortex. Revision of short stem THA resembled the primary THA. If a standard implant can be used in a surgical revision instead of a longer revision stem, this can be considered as an advantage for the hip arthroplasty treatment concept. However, this only applies if the longevity of the first treatment with a short stem is comparable with that of a standard stem. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective. Several factors contribute to the duration of the hospital stay in patients that undergo to total hip arthroplasty (THA), either subjective or perioperative. However, no definite evidence has been provided on the role of any of these factors on the hospitalization length. The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay (LOS) in patients that underwent elective total hip arthroplasty. Materials and Methods. Medical records of patients that underwent THA since the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, renal function, whole blood count. and length of post-operative ward stay were retrieved. The association between clinical, biochemical and surgical factors and the length of hospital stay was explored by means of linear regression models. Results. A total of 743 subjects were included. Retrieved comorbidity included arterial hypertension (47%), dyslipidaemia (20%), chronic kidney disease (CKD) (12%) and diabetes mellitus (9%). The median length of post-operative hospital stay was 4 days (IQR: 2). Variables associated with linear increase of hospitalization length were the estimated Glomerular Filtration Rate (eGFR) (Beta −0.01, 95% CI −0.02, 0), CKD (Beta 0.82, 95% CI 0.29, 1.34), duration of surgery (Beta 0.69, 95% CI 0.44, 0.94). After correction for multiple confounders, the CKD (a-Beta 1.58 95%CI 0.00 – 3.22) and operation time (a-Beta 0.67, 95% CI 0.42, 0.92) were consistently associated with the outcome. Conclusions. Our analysis demonstrated a significant role played by the eGFR (as an index of renal function) in influencing the length of hospital stay

Introduction and Objective. Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years. Materials and Methods. A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively. Results. There was a 6.2% (n=28) all-cause and 5.3% (n=24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months − 11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15–95) pre-operatively to a mean of 15.6 (range 0–78) at 10 years. Conclusions. This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. The role for CoC bearings in THA has been called into question in recent years and may continue to decline in popularity, even in younger patients. Further large scale studies are important to assess the long-term outcomes of this bearing surface

Abstract. Objectives. Outcomes following different types of surgical intervention for FAI are well reported individually but comparative data is deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyse the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO) and surgical hip dislocation (SHD). Methods. 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 PRISMA guidelines. We specifically analysed and compared changes in patient reported outcome measures PROMs, α-angle, rate of complications, rate of revision and conversion to total hip arthroplasty (THA). Results. A total of 48 articles included for final analysis with a total of 4384 hips in 4094 patients. All subgroups showed a significant correction in mean alpha angle post-operatively with a mean change of 28.8° (95% CI, 21°-36.5°; p <0.01) after AMO, 21.1° (95% CI, 15.1°-27°; p <0.01) after SHD and 20.39° (95% CI, 15.66°-25.12°; p <0.01) after HA. AMO group showed a significantly higher increase in PROMs (3.7; 95% CI, 3.2–4.2; p <0.01) versus arthroscopy (2.47; 95% CI, 2.22–2.73; p <0.01) and SHD (2.4; 95% CI, 1.5–3.3; p <0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. Conclusion. All three surgical approaches offered significant improvements in outcomes and radiological correction of cam deformities. All three groups showed similar rates of revision procedures and SHD had the highest rate of conversion to a THA. Revision rates was similar for all three revision procedures

Abstract. Objectives. The objective of this proof of concept study was to explore whether some total hip arthroplasty (THA) patients with well-functioning implants achieve normal sagittal plane hip kinematics during walking gait. Methods. Sagittal plane hip kinematics were recorded in eleven people with well-functioning THA (71 ± 8 years, Oxford Hip Score = 46 ± 3) and ten healthy controls (61 ± 5 years) using a three-dimensional motion capture system as they walked over-ground at a self-selected velocity. THA patients were classified as high- or low-functioning (HF and LF, respectively) depending on whether the mean absolute difference between their sagittal plane hip kinematics was within one standard deviation of the control group (5.4°) or not. Hedge's g effect size was used to compare the magnitude of the difference from the control group for the HF and LF THA groups. Results. Five THA patients were identified as HF and 6 as LF. The mean absolute difference in sagittal plane hip kinematics between the THA groups and the control group was on average 6.2° larger for the LF THA patients compared to the HF, with this difference associated with a large effect size (g = 1.84). Conclusions. The findings of this study challenge the findings of previous work which suggests THA patients do not achieve normal sagittal plane hip kinematics. Five patients were classified as HR and achieved motion patterns that were on average within the variance of the asymptomatic control group, suggesting normative sagittal plane hip kinematics. Understanding why some THA patients achieve motion patterns more comparable to healthy controls than others would help to develop means of maximising functional recovery, and potentially enhance both patient quality of life and implant survivorship through more normal loading of the implant