L. Spencer-Gardner, J. Pierrepont, M. Topham, J. Baré, S. McMahon, A. J. Shimmin Patient-specific instrumentation improves the accuracy of acetabular component placement in total hip arthroplasty. Bone Joint J 2016;98-B:1342–1346

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To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores.

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Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs.

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The aim of this study was to evaluate the performance of metagenomic next-generation sequencing (mNGS) in detecting pathogens from synovial fluid of prosthetic joint infection (PJI) patients.

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Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors.

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As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

C.D. Watts, J.R. Martin, M. T. Houdek, M. P. Abdel, D. G.Lewallen, M. J. Taunton Prior bariatric surgery may decrease the rate of reoperation and revision following total hip arthroplasty. Bone Joint J 2016;98-B:1180–1184

The purpose of this study was to determine patient-reported outcomes of patients with mild to moderate developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) undergoing arthroscopy of the hip in the treatment of chondrolabral pathology. A total of 28 patients with a centre-edge angle between 15° and 19° were identified from an institutional database. Their mean age was 34 years (18 to 53), with 12 female and 16 male patients. All underwent labral treatment and concomitant correction of FAI. There were nine reoperations, with two patients requiring revision arthroscopy, two requiring periacetabular osteotomy and five needing total hip arthroplasty. Patients who required further major surgery were more likely to be older, male, and to have more severe DDH with a larger alpha angle and decreased joint space. . At a mean follow-up of 42 months (24 to 89), the mean modified Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p < 0.001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to 43; p < 0.001). Median patient satisfaction was 9.0/10 (1 to 10). Patients reported excellent improvement in function following arthroscopy of the hip. This study shows that with proper patient selection, arthroscopy of the hip can be successful in the young patient with mild to moderate DDH and FAI. . Cite this article: Bone Joint J 2015;97-B:1316–21

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This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy.

We dissected 20 cadaver hips in order to investigate the anatomy and excursion of the trochanteric muscles in relation to the posterior approach for total hip replacement. String models of each muscle were created and their excursion measured while the femur was moved between its anatomical position and the dislocated position. The position of the hip was determined by computer navigation. In contrast to previous studies which showed a separate insertion of piriformis and obturator internus, our findings indicated that piriformis inserted onto the superior and anterior margins of the greater trochanter through a conjoint tendon with obturator internus, and had connections to gluteus medius posteriorly. Division of these connections allowed lateral mobilisation of gluteus medius with minimal retraction. Analysis of the excursion of these muscles revealed that positioning the thigh for preparation of the femur through this approach elongated piriformis to a maximum of 182%, obturator internus to 185% and obturator externus to 220% of their resting lengths, which are above the thresholds for rupture of these muscles. Our findings suggested that gluteus medius may be protected from overstretching by release of its connection with the conjoint tendon. In addition, failure to detach piriformis or the obturators during a posterior approach for total hip replacement could potentially produce damage to these muscles because of over-stretching, obturator externus being the most vulnerable

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.

Objectives. Computed tomography (CT) plays an important role in evaluating wear and periacetabular osteolysis (PAO) in total hip replacements. One concern with CT is the high radiation exposure since standard pelvic CT provides approximately 3.5 millisieverts (mSv) of radiation exposure, whereas a planar radiographic examination with three projections totals approximately 0.5 mSv. The objective of this study was to evaluate the lowest acceptable radiation dose for dual-energy CT (DECT) images when measuring wear and periacetabular osteolysis in uncemented metal components. Materials and Methods. A porcine pelvis with bilateral uncemented hip prostheses and with known linear wear and acetabular bone defects was examined in a third-generation multidetector DECT scanner. The examinations were performed with four different radiation levels both with and without iterative reconstruction techniques. From the high and low peak kilo voltage acquisitions, polychrmoatic images were created together with virtual monochromatic images of energies 100 kiloelectron volts (keV) and 150 keV. Results. We could assess wear and PAO while substantially lowering the effective radiation dose to 0.7 mSv for a total pelvic view with an accuracy of around 0.5 mm for linear wear and 2 mm to 3 mm for PAO. Conclusion. CT for detection of prosthetic wear and PAO could be used with clinically acceptable accuracy at a radiation exposure level equal to plain radiographic exposures. Cite this article: B. Sandgren, M. Skorpil, P. Nowik, H. Olivecrona, J. Crafoord, L. Weidenhielm, A. Persson. Assessment of wear and periacetabular osteolysis using dual energy computed tomography on a pig cadaver to identify the lowest acceptable radiation dose. Bone Joint Res 2016;5:307–313. DOI: 10.1302/2046-3758.57.2000566

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The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures

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The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018.

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Femoral revision component subsidence has been identified as predicting early failure in revision hip surgery. This comparative cohort study assessed the potential risk factors of subsidence in two commonly used femoral implant designs.

The accurate reconstruction of hip anatomy and biomechanics is thought to be important in achieveing good clinical outcomes following total hip arthroplasty (THA). To this end some newer hip designs have introduced further modularity into the design of the femoral component such that neck­shaft angle and anteversion, which can be adjusted intra-operatively. The clinical effect of this increased modularity is unknown. We have investigated the changes in these anatomical parameters following conventional THA with a prosthesis of predetermined neck–shaft angle and assessed the effect of changes in the hip anatomy on clinical outcomes. . In total, 44 patients (mean age 65.3 years (standard deviation (. sd. ) 7); 17 male/27 female; mean body mass index 26.9 (kg/m²) (. sd. 3.1)) underwent a pre- and post-operative three-dimensional CT scanning of the hip. The pre- and post-operative neck–shaft angle, offset, hip centre of rotation, femoral anteversion, and stem alignment were measured. Additionally, a functional assessment and pain score were evaluated before surgery and at one year post-operatively and related to the post-operative anatomical changes. The mean pre-operative neck–shaft angle was significantly increased by 2.8° from 128° (. sd.  6.2; 119° to 147°) to 131° (. sd. 2.1; 127° to 136°) (p = 0.009). The mean pre-operative anteversion was 24.9° (. sd. 8; 7.9 to 39.1) and reduced to 7.4° (. sd. 7.3; -11.6° to 25.9°) post-operatively (p < 0.001). The post-operative changes had no influence on function and pain. Using a standard uncemented femoral component, high pre- and post-operative variability of femoral anteversion and neck–shaft angles was found with a significant decrease of the post-operative anteversion and slight increase of the neck–shaft angles, but without any impact on clinical outcome. Cite this article: Bone Joint J 2015;97-B:1615–22

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement. Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients

The February 2014 Hip & Pelvis Roundup. 360 . looks at: length of stay; cementless metaphyseal fixation; mortality trends in over 400,000 total hip replacements; antibiotics in hip fracture surgery; blood supply to the femoral head after dislocation; resurfacing and THR in metal-on-metal replacement; diabetes and hip replacement; bone remodelling over two decades following hip replacement; and whether bisphosphonates affect acetabular fixation