Aims. Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS). Methods. Retrospectively collected data of 38 patients (39 hips) with pelvic discontinuity treated with revision THA using a custom-made triflange acetabular component were analyzed. Minimum follow-up was two years (mean 5.1 years (2 to 11)). Results. There were eight subsequent surgical interventions. Two failures (5%) of the triflange acetabular components were both revised because of deep infection. There were seven (18%) patients with dislocation, and five (13%) of these were treated with a constraint liner. One patient had a debridement, antibiotics, and implant retention (DAIR) procedure. In 34 (92%) hips the custom-made triflange component was considered stable, with a healed pelvic discontinuity with no aseptic loosening at midterm follow-up. Mean HHS was 80.5 (48 to 96). Conclusion. The performance of the custom triflange implant in this study is encouraging, with high rates of discontinuity healing and osteointegration of the acetabular implant with no aseptic loosening at midterm follow-up. However, complications are not uncommon, particularly instability which we successfully addressed with constrained liners. Cite this article: Bone Jt Open 2022;3(11):867–876

Aims. This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices. Methods. Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries. Results. The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices. Conclusion. This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices. Cite this article: Bone Jt Open 2024;5(9):742–748

Aims. A revision for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) has a major effect on the patient’s quality of life, including walking capacity. The objective of this case control study was to investigate the histological and ultrastructural changes to the gluteus medius tendon (GMED) in patients revised due to a PJI, and to compare it with revision THAs without infection performed using the same lateral approach. Methods. A group of eight patients revised due to a PJI with a previous lateral approach was compared with a group of 21 revised THAs without infection, performed using the same approach. The primary variables of the study were the fibril diameter, as seen in transmission electron microscopy (TEM), and the total degeneration score (TDS), as seen under the light microscope. An analysis of bacteriology, classification of infection, and antibiotic treatment was also performed. Results. Biopsy samples from the GMED from infected patients revealed a larger fibril diameter than control patients, as seen in the TEM (p < 0.001). Uninfected patients were slightly older and had their revisions performed significantly later than the infected patients. Histologically, samples from infected patients revealed significantly more vascularity (p < 0.001), the presence of glycosaminoglycans (p < 0.001), and a higher TDS (p = 0.003) than the control patients. The majority of patients had staphylococcal infections of various species. Conclusion. More histological degeneration in the GMED was found in patients undergoing THA revision surgery due to PJI than in patients undergoing THA revision surgery due to other reasons. Cite this article: Bone Jt Open 2023;4(8):628–635

Aims. Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation. Methods. This was a retrospective cohort study of patients who underwent THA surgery that included 23 symptomatic patients diagnosed with iliopsoas tendonitis, and 23 patients not diagnosed with iliopsoas tendonitis. All patients received postoperative CT imaging, postoperative standing radiography, and had minimum six months’ follow-up. 3D models of each patient’s prosthetic and bony anatomy were generated, landmarked, and simulated in a novel iliopsoas impingement detection model in supine and standing pelvic positions. Logistic regression models were implemented to determine if the probability of pain could be significantly predicted. Receiver operating characteristic curves were generated to determine the model’s sensitivity, specificity, and area under the curve (AUC). Results. Highly significant differences between the symptomatic and asymptomatic cohorts were observed for iliopsoas impingement. Logistic regression models determined that the impingement values significantly predicted the probability of groin pain. The simulation had a sensitivity of 74%, specificity of 100%, and an AUC of 0.86. Conclusion. We developed a computational model that can quantify iliopsoas impingement and verified its accuracy in a case-controlled investigation. This tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis. Cite this article: Bone Jt Open 2023;4(1):3–12

Aims. The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population. Methods. We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed. Results. There were 143 patients included in the fittest cohort. Mean age was 66 years (SD 4.5) and 103 were female (72%). No clinically relevant differences were found between the treatment groups in the primary and sensitivity analyses. Conclusion. This analysis found no differences in functional outcomes between HA and THA within two years of displaced low-energy FNF in a subgroup analysis of the fittest HEALTH patients. These findings suggest that very few patients above 50 years of age benefit in a clinically meaningful way from a THA versus a HA early after injury. Cite this article: Bone Jt Open 2022;3(8):611–617

Aims. Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD. Methods. In all, 93 patients who underwent a THA received a standardized preoperative EOS scan, anteroposterior (AP) radiograph, and clinical LLD assessment. Overall, 13 measurements were taken along both anatomical and functional axes and measured twice by an orthopaedic fellow and surgical planning engineer to calculate intraoperator reproducibility and correlations between measurements. Results. Strong correlations were observed for all EOS measurements (r. s. > 0.9). The strongest correlation with AP radiograph (inter-teardrop line) was observed for functional-ASIS-to-floor (functional) (r. s. = 0.57), much weaker than the correlations between EOS measurements. ASIS-to-ankle measurements exhibited a high correlation to other linear measurements and the highest ICC (r. s. = 0.97). Using anterior superior iliac spine (ASIS)-to-ankle, 33% of patients had an absolute LLD of greater than 10 mm, which was statistically different from the inter-teardrop LLD measurement (p < 0.005). Discussion. We found that the conventional measurement of LLD on AP pelvic radiograph does not correlate well with long leg measurements and may not provide a true appreciation of LLD. ASIS-to-ankle demonstrated improved detection of potential LLD than other EOS and radiograph measurements. Full length, functional imaging methods may become the new gold standard to measure LLD. Cite this article: Bone Jt Open 2022;3(12):960–968

Aims. Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up. Methods. We retrospectively evaluated 11 hips in 11 patients who underwent osteochondral autograft transfer in our institution between 1996 and 2012. The mean age at the time of surgery was 28.6 years (8 to 45). Outcome measurement included standardized scores and conventional radiographs. Kaplan-Meier survival curve was used to determine the failure of the procedures, with conversion to total hip arthroplasty (THA) defined as the endpoint. Results. The mean follow-up of patients treated with osteochondral autograft transfer was 18.5 years (9.3 to 24.7). Six patients developed osteoarthritis and had a THA at a mean of 10.3 years (1.1 to 17.3). The cumulative survivorship of the native hips was 91% (95% confidence interval (CI) 74 to 100) at five years, 62% (95% CI 33 to 92) at ten years, and 37% (95% CI 6 to 70) at 20 years. Conclusion. This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head. Although most patients underwent conversion to THA in the long term, over half of them survived more than ten years. Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions who have virtually no other surgical options. A larger series or a similar matched cohort would be necessary to confirm these results which, in view of the heterogeneity of our series, seems difficult to achieve. Cite this article: Bone Jt Open 2023;4(7):523–531

Aims. Computer-assisted 3D preoperative planning software has the potential to improve postoperative stability in total hip arthroplasty (THA). Commonly, preoperative protocols simulate two functional positions (standing and relaxed sitting) but do not consider other common positions that may increase postoperative impingement and possible dislocation. This study investigates the feasibility of simulating commonly encountered positions, and positions with an increased risk of impingement, to lower postoperative impingement risk in a CT-based 3D model. Methods. A robotic arm-assisted arthroplasty planning platform was used to investigate 11 patient positions. Data from 43 primary THAs were used for simulation. Sacral slope was retrieved from patient preoperative imaging, while angles of hip flexion/extension, hip external/internal rotation, and hip abduction/adduction for tested positions were derived from literature or estimated with a biomechanical model. The hip was placed in the described positions, and if impingement was detected by the software, inspection of the impingement type was performed. Results. In flexion, an overall impingement rate of 2.3% was detected for flexed-seated, squatting, forward-bending, and criss-cross-sitting positions, and 4.7% for the ankle-over-knee position. In extension, most hips (60.5%) were found to impinge at or prior to 50° of external rotation (pivoting). Many of these impingement events were due to a prominent ischium. The mean maximum external rotation prior to impingement was 45.9° (15° to 80°) and 57.9° (20° to 90°) prior to prosthetic impingement. No impingement was found in standing, sitting, crossing ankles, seiza, and downward dog. Conclusion. This study demonstrated that positions of daily living tested in a CT-based 3D model show high rates of impingement. Simulating additional positions through 3D modelling is a low-cost method of potentially improving outcomes without compromising patient safety. By incorporating CT-based 3D modelling of positions of daily living into routine preoperative protocols for THA, there is the potential to lower the risk of postoperative impingement events. Cite this article: Bone Jt Open 2023;4(6):416–423

Aims. The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy. Methods. We included patients who underwent THA using Wagner Cone due to proximal femur anatomical abnormalities between August 2014 and January 2019 at a single institution. We investigated implant survival time using the endpoint of dislocation and revision, and compared the prevalence of prosthetic impingements between the Wagner Cone, a tapered cone stem, and the Taperloc, a tapered wedge stem, through simulation. We also collected Oxford Hip Score (OHS), visual analogue scale (VAS) satisfaction, and VAS pain by postal survey in August 2023 and explored variables associated with those scores. Results. Of the 58 patients (62 hips), two (two hips) presented with dislocation or reoperation, and Kaplan-Meier analysis indicated a five-year survival rate of 96.7% (95% CI 92.4 to 100). Mean stem anteversion was 35.2° (SD 18.2°) for the Taperloc stem and 29.8° (SD 7.9°) for the Wagner Cone stem; mean reduction from Taperloc to Wagner Cone was 5.4° (SD 18.8°). Overall, 55 hips (52 patients) were simulated, and the prevalence of prosthetic impingement was lower for the Wagner Cone (5.5%, 3/55) compared with the Taperloc (20.0%, 11/55) stem, with an odds ratio of 0.20 (p = 0.038). Among the 33 respondents to the postal survey (36 hips), the mean scores were VAS pain 10.9, VAS satisfaction 86.9, and OHS 44.7. A multivariable analysis revealed that reduction of stem anteversion from Taperloc to Wagner Cone was more favourable for VAS pain (p = 0.029) and VAS satisfaction (p = 0.002). Conclusion. The mid-term survival rate for THA using the Wagner Cone stem was high, which may be supported by a reduction in prosthetic impingement. The reduction in excessive stem anteversion by using a tapered cone stem was associated with reduced pain and increased patient satisfaction. Cite this article: Bone Jt Open 2024;5(10):858–867

Aims. Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. Methods. We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA. Results. Robotic-assisted THA resulted in a lower proportion (1.5%) of implant waste compared to navigation-guided THA (2.0%) and manual THA (1.9%) (all p < 0.001). Both navigated and manual THA were more likely to waste acetabular shells (odds ratio (OR) 4.5 vs 3.1) and polyethylene liners (OR 2.2 vs 2.0) compared to robotic-assisted THA after adjusting for demographic and perioperative factors, such as surgeon experience (p < 0.001). While implant waste decreased with increasing experience for procedures performed manually (p < 0.001) or with navigation (p < 0.001), waste rates for robotic-assisted THA did not differ based on surgical experience. Conclusion. Robotic-assisted THAs wasted a smaller proportion of acetabular shells and polyethylene liners than navigation-guided and manual THAs. Individual implant waste rates vary depending on the type of technology used intraoperatively. Future studies on implant waste during THA should examine reasons for non-implantation in order to better understand and develop methods for cost-saving. Cite this article: Bone Jt Open 2024;5(8):715–720

Aims. The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA). Methods. Data were extracted from a single centre prospective database of patients with PD who were treated with a CTAC. Patients were included if they had a follow-up of two years. The Hip Disability and Osteoarthritis Outcome Score (HOOS), modified Oxford Hip Score (mOHS), EurQol EuroQoL five-dimension three-level (EQ-5D-3L) utility, and Numeric Rating Scale (NRS), including visual analogue score (VAS) for pain, were gathered at baseline, and at one- and two-year follow-up. Reasons for revision, and radiological and clinical complications were registered. Trends over time are described and tested for significance and clinical relevance. Results. A total of 18 females with 22 CTACs who had a mean age of 73.5 years (SD 7.7) were included. A significant improvement was found in HOOS (p < 0.0001), mOHS (p < 0.0001), EQ-5D-3L utility (p = 0.003), EQ-5D-3L NRS (p = 0.013), VAS pain rest (p = 0.008), and VAS pain activity (p < 0.0001) between baseline and final follow-up. Minimal clinically important improvement in mOHS and the HOOS Physical Function Short Form (HOOS-PS) was observed in 16 patients (73%) and 14 patients (64%), respectively. Definite healing of the PD was observed in 19 hips (86%). Complications included six cases with broken screws (27%), four cases (18%) with bony fractures, and one case (4.5%) with sciatic nerve paresthesia. One patient with concurrent bilateral PD had revision surgery due to recurrent dislocations. No revision surgery was performed for screw failure or implant breakage. Conclusion. CTAC in patients with THA acetabular loosening and PD can result in stable constructs and significant improvement in functioning and health-related quality of life at two years' follow-up. Further follow-up is necessary to determine the mid- to long-term outcome. Cite this article: Bone Jt Open 2023;4(2):53–61

Aims. It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA. Methods. In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound. Results. The median sound pressure (SP) of successful fixation at 0.5 to 1.0 kHz was higher than that of unsuccessful fixation (0.0694 (interquartile range (IQR) 0.04721 to 0.09576) vs 0.05425 (IQR 0.03047 to 0.06803), p < 0.001). The median SP of successful fixation at 3.5 to 4.0 kHz and 4.0 to 4.5 kHz was lower than that of unsuccessful fixation (0.0812 (IQR 0.05631 to 0.01161) vs 0.1233 (IQR 0.0730 to 0.1449), p < 0.001; and 0.0891 (IQR 0.0526 to 0.0891) vs 0.0885 (IQR 0.0716 to 0.1048); p < 0.001, respectively). There was a statistically significant positive relationship between body weight and SP at 0.5 to 1.0 kHz (p < 0.001). Multivariate analyses indicated that the SP at 0.5 to 1.0 kHz and 3.5 to 4.0 kHz was independently associated with the successful fixation. Conclusion. The frequency bands of 0.5 to 1.0 and 3.5 to 4.0 kHz were the key to distinguish the sound characteristics between successful and unsuccessful press-fit cup fixation. Cite this article: Bone Jt Open 2024;5(3):154–161

Aims. It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA. Methods. In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound. Results. The median sound pressure (SP) of successful fixation at 0.5 to 1.0 kHz was higher than that of unsuccessful fixation (0.0694 (interquartile range (IQR) 0.04721 to 0.09576) vs 0.05425 (IQR 0.03047 to 0.06803), p < 0.001). The median SP of successful fixation at 3.5 to 4.0 kHz and 4.0 to 4.5 kHz was lower than that of unsuccessful fixation (0.0812 (IQR 0.05631 to 0.01161) vs 0.1233 (IQR 0.0730 to 0.1449), p < 0.001; and 0.0891 (IQR 0.0526 to 0.0891) vs 0.0885 (IQR 0.0716 to 0.1048); p < 0.001, respectively). There was a statistically significant positive relationship between body weight and SP at 0.5 to 1.0 kHz (p < 0.001). Multivariate analyses indicated that the SP at 0.5 to 1.0 kHz and 3.5 to 4.0 kHz was independently associated with the successful fixation. Conclusion. The frequency bands of 0.5 to 1.0 and 3.5 to 4.0 kHz were the key to distinguish the sound characteristics between successful and unsuccessful press-fit cup fixation. Cite this article: Bone Jt Open 2024;4(3):154–161

Aims. Traditionally, total hip arthroplasty (THA) templating has been performed on anteroposterior (AP) pelvis radiographs. Recently, additional AP hip radiographs have been recommended for accurate measurement of the femoral offset (FO). To verify this claim, this study aimed to establish quantitative data of the measurement error of the FO in relation to leg position and X-ray source position using a newly developed geometric model and clinical data. Methods. We analyzed the FOs measured on AP hip and pelvis radiographs in a prospective consecutive series of 55 patients undergoing unilateral primary THA for hip osteoarthritis. To determine sample size, a power analysis was performed. Patients’ position and X-ray beam setting followed a standardized protocol to achieve reproducible projections. All images were calibrated with the KingMark calibration system. In addition, a geometric model was created to evaluate both the effects of leg position (rotation and abduction/adduction) and the effects of X-ray source position on FO measurement. Results. The mean FOs measured on AP hip and pelvis radiographs were 38.0 mm (SD 6.4) and 36.6 mm (SD 6.3) (p < 0.001), respectively. Radiological view had a smaller effect on FO measurement than inaccurate leg positioning. The model showed a non-linear relationship between projected FO and femoral neck orientation; at 30° external neck rotation (with reference to the detector plane), a true FO of 40 mm was underestimated by up to 20% (7.8 mm). With a neutral to mild external neck rotation (≤ 15°), the underestimation was less than 7% (2.7 mm). The effect of abduction and adduction was negligible. Conclusion. For routine THA templating, an AP pelvis radiograph remains the gold standard. Only patients with femoral neck malrotation > 15° on the AP pelvis view, e.g. due to external rotation contracture, should receive further imaging. Options include an additional AP hip view with elevation of the entire affected hip to align the femoral neck more parallel to the detector, or a CT scan in more severe cases. Cite this article: Bone Jt Open 2022;3(10):795–803

Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion. SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691

Aims. After failed acetabular fractures, total hip arthroplasty (THA) is a challenging procedure and considered the gold standard treatment. The complexity of the procedure depends on the fracture pattern and the initial fracture management. This study’s primary aim was to evaluate patient-reported outcome measures (PROMs) for patients who underwent delayed uncemented acetabular THA after acetabular fractures. The secondary aims were to assess the radiological outcome and the incidence of the associated complications in those patients. Methods. A total of 40 patients underwent cementless acetabular THA following failed treatment of acetabular fractures. The postoperative clinical and radiological outcomes were evaluated for all the cohort. Results. The median (interquartile range (IQR)) Oxford Hip Score (OHS) improved significantly from 9.5 (7 to 11.5), (95% confidence interval (CI) (8 to 10.6)) to 40 (39 to 44), (95% CI (40 to 43)) postoperatively at the latest follow-up (p < 0.001). It was worth noting that the initial acetabular fracture type (simple vs complex), previous acetabular treatment (ORIF vs conservative), fracture union, and restoration of anatomical centre of rotation (COR) did not affect the final OHS. The reconstructed centre of rotation (COR) was restored in 29 (72.5%) patients. The mean abduction angle in whom acetabular fractures were managed conservatively was statistically significantly higher than the surgically treated patients 42.6° (SD 7.4) vs 38° (SD 5.6)) (p = 0.032). We did not have any case of acetabular or femoral loosening at the time of the last follow-up. We had two patients with successful two-stage revision for infection with overall eight-year survival rate was 95.2% (95% CI 86.6% to 100%) with revision for any reason at a median (IQR) duration of follow-up 50 months (16 to 87) months following THA. Conclusion. Delayed cementless acetabular THA in patients with previous failed acetabular fracture treatments produces good clinical outcomes (PROMS) with excellent survivorship, despite the technically demanding nature of the procedure. The initial fracture treatment does not influence the outcome of delayed THA. In selected cases of acetabular fractures (either nondisplaced or with secondary congruency), the initial nonoperative treatment neither resulted in large acetabular defects nor required additional acetabular reconstruction at the time of THA. Cite this article: Bone Jt Open 2021;2(12):1067–1074

Aims. Precise implant positioning, tailored to individual spinopelvic biomechanics and phenotype, is paramount for stability in total hip arthroplasty (THA). Despite a few studies on instability prediction, there is a notable gap in research utilizing artificial intelligence (AI). The objective of our pilot study was to evaluate the feasibility of developing an AI algorithm tailored to individual spinopelvic mechanics and patient phenotype for predicting impingement. Methods. This international, multicentre prospective cohort study across two centres encompassed 157 adults undergoing primary robotic arm-assisted THA. Impingement during specific flexion and extension stances was identified using the virtual range of motion (ROM) tool of the robotic software. The primary AI model, the Light Gradient-Boosting Machine (LGBM), used tabular data to predict impingement presence, direction (flexion or extension), and type. A secondary model integrating tabular data with plain anteroposterior pelvis radiographs was evaluated to assess for any potential enhancement in prediction accuracy. Results. We identified nine predictors from an analysis of baseline spinopelvic characteristics and surgical planning parameters. Using fivefold cross-validation, the LGBM achieved 70.2% impingement prediction accuracy. With impingement data, the LGBM estimated direction with 85% accuracy, while the support vector machine (SVM) determined impingement type with 72.9% accuracy. After integrating imaging data with a multilayer perceptron (tabular) and a convolutional neural network (radiograph), the LGBM’s prediction was 68.1%. Both combined and LGBM-only had similar impingement direction prediction rates (around 84.5%). Conclusion. This study is a pioneering effort in leveraging AI for impingement prediction in THA, utilizing a comprehensive, real-world clinical dataset. Our machine-learning algorithm demonstrated promising accuracy in predicting impingement, its type, and direction. While the addition of imaging data to our deep-learning algorithm did not boost accuracy, the potential for refined annotations, such as landmark markings, offers avenues for future enhancement. Prior to clinical integration, external validation and larger-scale testing of this algorithm are essential. Cite this article: Bone Jt Open 2024;5(8):671–680

Aims. There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. Methods. Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m. 2. who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m. 2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. Results. No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). Conclusion. Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4–11

Aims. Bone marrow-derived mesenchymal stem cells obtained from bone marrow aspirate concentrate (BMAC) with platelet-rich plasma (PRP), has been used as an adjuvant to hip decompression. Early results have shown promise for hip preservation in patients with osteonecrosis (ON) of the femoral head. The purpose of the current study is to examine the mid-term outcome of this treatment in patients with precollapse corticosteroid-induced ON of the femoral head. Methods. In all, 22 patients (35 hips; 11 males and 11 females) with precollapse corticosteroid-induced ON of the femoral head underwent hip decompression combined with BMAC and PRP. Mean age and BMI were 43 years (SD 12) and 31 kg/m² (SD 6), respectively, at the time of surgery. Survivorship free from femoral head collapse and total hip arthroplasty (THA) and risk factors for progression were evaluated at minimum five-years of clinical follow-up with a mean follow-up of seven years (5 to 8). Results. Survivorship free from femoral head collapse and THA for any reason was 84% and 67% at seven years postoperatively, respectively. Risk factors for conversion to THA included a high preoperative modified Kerboul angle (grade 3 or 4) based on preoperative MRI (hazard ratio (HR) 3.96; p = 0.047) and corticosteroid use at the time of decompression (HR 4.15; p = 0.039). The seven-year survivorship for patients with grade 1 or 2 Kerboul angles for conversion to THA for articular collapse, and THA for any reason, were 96% and 72%, respectively, versus THA for articular collapse and THA for any reason in patients with grade 3 or 4 Kerboul angles of 40% (p = 0.003) and 40% (p = 0.032). Conclusion. At seven years, hip decompression augmented with BMAC and PRP provided a 67% survivorship free from THA in patients with corticosteroid-induced ON. Ideal candidates for this procedure are patients with low preoperative Kerboul angles and can stop corticosteroid treatment prior to decompression. Cite this article: Bone Jt Open 2021;2(11):926–931

Aims. The aim of this study was to perform a cross-cultural adaptation of Oxford Hip Score (OHS) to Indonesian, and to evaluate its psychometric properties. Methods. We performed a cross-cultural adaptation of Oxford Hip Score into Indonesian language (OHS-ID) and determined its internal consistency, test-retest reliability, measurement error, floor-ceiling effect, responsiveness, and construct validity by hypotheses testing of its correlation with Harris Hip Score (HHS), vsual analogue scale (VAS), and Short Form-36 (SF-36). Adults (> 17 years old) with chronic hip pain (osteoarthritis or osteonecrosis) were included. Results. A total of 125 patients were included, including 50 total hip arthroplasty (THA) patients with six months follow-up. The OHS questionnaire was translated into Indonesian and showed good internal consistency (Cronbach’s alpha = 0.89) and good reliability (intraclass correlation = 0.98). The standard error of measurement value of 2.11 resulted in minimal detectable change score of 5.8. Ten out of ten (100%) a priori hypotheses were met, confirming the construct validity. A strong correlation was found with two subscales of SF-36 (pain and physical function), HHS (0.94), and VAS (-0.83). OHS-ID also showed good responsiveness for post-THA series. Floor and ceiling effect was not found. Conclusion. The Indonesian version of OHS showed similar reliability and validity with the original OHS. This questionnaire will be suitable to assess chronic hip pain in Indonesian-speaking patients. Cite this article: Bone Jt Open 2021;2(9):765–772