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Background: Management of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity. Methods: A retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis. Results: Four patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period. Conclusions: We have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

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INTRODUCTION: The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA). MATERIALS AND METHODS: A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs. RESULTS: Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID). CONCLUSIONS: Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

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BACKGROUND: Ischiofemoral impingement (IFI) is understood to be a pain generator in the deep gluteal space. Femoral position is known to influence the ischiofemoral space (IFS), but there has been no study examining the effect of sagittal pelvic tilt on the IFS. The purpose of this study was to determine whether changes in pelvic tilt in the sagittal plane lead to changes in the dimensions of the IFS. MATERIALS AND METHODS: Five fresh frozen cadavers (10 hips) were used for this anatomic study. The specimens were skeletonized and placed in the prone position with the pelvis fixed to a custom-built hinged table. A digital inclinometer was used to tilt the pelvis -10°, 0°, and 10° simulating posterior, neutral, and anterior pelvic tilt, respectively. Digital calipers were used to measure the dimensions of the IFS in all three positions of sagittal pelvic tilt. RESULTS: Changes in pelvic tilt resulted in significant changes in the dimensions of the IFS. Mean IFS dimensions measured 29.3±9.7 mm, 37.2±9.0 mm, and 24.3±9.2 mm in the neutral, anterior, and posterior pelvic tilt positions, respectively (P<.0001). CONCLUSION: Changes in sagittal pelvic tilt influence the dimensions of the IFS, with posterior pelvic tilt noted to significantly decrease the IFS when compared with neutral and anterior pelvic tilt. These findings suggest that further evaluation of sagittal spinopelvic balance in the etiology of symptomatic IFI may be warranted. [Orthopedics. 2024;47(3):167-171.].

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INTRODUCTION: The personality traits of those who become orthopaedic surgeons may also lead to overwork, work-life balance issues, and burnout. Health and wellness practices of orthopaedic surgeons have not been widely explored. This study evaluated the personal health habits, wellness, and burnout of practicing orthopaedic surgeons in the United States. METHODS: An anonymous self-assessment survey was completed by 234 practicing orthopaedic surgeon alumni from two large residency programs. The survey assessed exercise habits according to Centers for Disease Control and Prevention recommendations, compliance with preventive medical care practices according to the United States Preventive Services Task Force, prioritization of occupational wellness strategies, and the presence of burnout via an adapted Maslach Burnout Inventory. Survey responders' mean age was 52 years, 88% were male, and 93% had a body mass index <30 kg/m2. Surgeons were stratified according to practice type, years in practice, and subspecialty. RESULTS: Among orthopaedic surgeons, compliance with aerobic and strength exercise recommendations was 31%. Surgeons in academic practice were significantly (P = 0.007) less compliant with exercise recommendations (18%) compared with private (34%) or employed (43%) practicing surgeons. Most (71%) had seen their primary care provider within 2 years and were up to date on age-appropriate health care screening including a cholesterol check within 5 years (79%), colonoscopy (89%), and mammogram (92%). Protecting time away from work for family/friends and finding meaning in work were the most important wellness strategies. The overall burnout rate was 15% and remained not significantly different (P > 0.3) regardless of years in practice, practice type, or subspecialty. CONCLUSION: This survey study identifies practicing orthopaedic surgeons' health habits and wellness strategies, including limited compliance with aerobic and strength exercise recommendations. Orthopaedic surgeons should be aware of areas of diminished personal wellness to improve quality of life and avoid burnout.

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BACKGROUND: For patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes. METHODS: Our total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12). RESULTS: For CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients. CONCLUSION: Complications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.

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BACKGROUND: Solid organ transplant (SOT) patients have increased risk of complications, infection, and mortality after elective total hip arthroplasty (THA). The study aims to compare SOT recipients' clinical outcomes to a matched group of nontransplant patients after nonelective THA and hemiarthroplasty for acute femoral neck fracture (FNF). METHODS: A retrospective review identified 31 SOT patients undergoing hip arthroplasty (24 hemiarthroplasty and 7 THA) for FNF and were matched 1:1 to non-SOT patients based on age, sex, body mass index, surgical procedure, and year of surgery. Patient survivorship, perioperative outcomes, complications, and reoperations were compared. The mean follow-up was 3 years. RESULTS: The estimated survivorship free from mortality for SOT and non-SOT patients at 1- year was not different (77% and 84%, respectively, P = .52). The 90-day readmission rate was significantly higher with 8 (26%) in the SOT cohort and none in the non-SOT group (P < .01). Major medical complications occurred in 16% of SOT patients compared to 5% in controls (P = .21). Three (10%) reoperations/revisions were required for SOT patients and none in non-SOT group (P = .24). CONCLUSION: SOT recipients undergoing nonelective hip arthroplasty for FNF demonstrated increased readmission rates compared to matched controls. For this rare clinical scenario, diligent perioperative care by surgeons and multidisciplinary transplant specialists is necessary to mitigate increased risk of SOT patients.

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Hip arthroscopy (HA) is an established treatment option to address intra-articular pathology of the hip. However, some clinicians encourage non-operative management (NOM). Non-operative management may include active measures such as physiotherapy and intra-articular steroid injections, or NOM may involve so called watchful waiting with no active intervention. These approaches, along with surgery have been detailed recently in the Warwick Agreement, a Consensus Statement regarding diagnosis and treatment of Femoroacetabular Impingement Syndrome The aim of this study is to compare the change in clinical outcome scores of waitlisted patients with intra-articular hip pathology who receive no active treatment with matched controls that have undergone HA. Patients less than 60 years of age were identified from a HA waiting list in a single hospital in the Australian public hospital system. Patient reported outcomes (PRO) were collected whilst patients waited for surgery. During this waiting period no specific treatment was offered. A separate group of patients who had previously undergone HA were matched based on age, sex, body mass index and baseline non-arthritic hip scores (NAHS). The groups were compared using the NAHS as the primary outcome measures. Modified Harris Hip Scores were also collected and compared. Thirty-six patients were included in each group, with a mean follow up of 19 months (12-36). There were no significant differences in age, sex, BMI and NAHS between groups at baseline. At final follow up, mean NAHS scores after HA were significantly higher than scores after NOM, 82.1 (36.4-100.0) versus 48.9 (11.3-78.8), respectively (P < 0.001) with a large effect size for mean change in scores between groups (d = 1.77, 95% CI 1.21-2.30). Mean mHHS after HA were significantly higher than scores after NOM, 84.3 (15.4-100.0) versus 48.1 (21.0-66.0) respectively (P < 0.001), with a large effect size for mean change in scores between groups (d = 1.92, 95% CI 1.34-2.46). HA may lead to significant improvements in PRO when compared to non-operative management of waitlisted patients with intra-articular pathology of the hip at 18 months follow-up.

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PURPOSE: The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement. METHODS: All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS). RESULTS: Ten patients with a mean age of 18 years (range 14-28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7-3.5), the median post-operative mHHS was 89.7 (65.7-96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal. CONCLUSION: Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Open and arthroscopic approaches have been described to address femoroacetabular impingement (FAI). Despite good outcomes, there is a subset of patients who subsequently require total hip arthroplasty (THA). However, there is a paucity of data on the outcomes of THA after surgery for FAI. The purpose of this study was to determine whether clinical outcomes of THA are affected by prior open or arthroscopic treatment of FAI. METHODS: This case-matched retrospective review included 23 patients (24 hips) that underwent THA after previous surgery for FAI (14 arthroscopic and 10 open) and compared them to 24 matched controls with no history of prior surgery on the operative hip. The controls were matched for age, sex, surgical approach, implants used, and preoperative modified Harris hip score (mHHS) did not differ between groups. The primary outcome measure was the mHHS. Operative time, blood loss, and the presence of heterotopic ossification after THA were also compared between groups. RESULTS: There was no significant difference in mean mHHS between the FAI treatment group 92.9 ± 12.7 and controls 95.2 ± 6.6 (P = .43) at a mean follow-up after THA of 33 (24-70) months. Increased operative times were noted for THA after surgical hip dislocation (SHD; mean 109.3 ± 29.8) compared to controls (mean 88.0 ± 24.2; P < .05). There was no significant difference in blood loss between groups. The occurrence of heterotopic ossification was significantly higher after SHD compared to controls (P < .05). CONCLUSIONS: Clinical outcomes after THA are not affected by prior open or arthroscopic procedures for FAI. However, increased operative times and an increased risk of heterotopic ossification were noted after SHD.

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The purpose of this study was to evaluate the accuracy and efficiency of three patellar resection techniques: cutting guide, free hand with haptic feedback, and a novel technique utilizing four quadrant measurements. Ninety patients undergoing TKA were randomized to receive patellar resurfacing by one of the three study techniques. The novel four quadrant technique resulted in least post-resection asymmetry (0.85 mm, P = 0.001). The most accurate methods for obtaining desired thickness were haptic feedback (0.66 mm mean discrepancy [MD]) and novel four quadrant technique (0.66 mm MD) followed by the patellar cutting guide (1.40 mm MD) (P < 0.001). Use of a patellar cutting guide resulted in increased patellar asymmetry and decreased accuracy in obtaining desired patellar thickness in this prospective trial.

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Painful hip snapping can present as a rare sequela of proximal hamstring injury. We present a case of painful snapping of the conjoint tendon of the semitendinosus and biceps femoris over the ischial tuberosity in the setting of a partial proximal hamstring disruption. Dynamic ultrasonography identified the source of snapping and a persistent attachment of the conjoint tendon to the sacrotuberous ligament, which prevented retraction and allowed subluxation of the tendons across the ischial tuberosity. Following surgical transection of the persistent sacrotuberous ligament attachment to the conjoint tendon and tendon reattachment, the patient's symptoms resolved with full return of function.

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This is one of the first documented cases of metal-on-metal (MoM) total hip arthroplasty cobalt cardiac toxicity that has led to patient death. A 69-year-old female presented to our institution with cardiac failure secondary to cobalt toxicity resulting from bilateral MoM total hip arthroplasty. Her presenting metal ion levels were a cobalt level of 199 ppb and a chromium level of 77 ppb. She underwent bilateral femoral revisions to remove the source of cobalt. On postoperative day 7, the patient sustained a cerebral infarct and eventually expired because of the insult. This case represents one of the first documented fatalities related to MoM cobalt cardiac toxicity.

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PURPOSE: Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data. METHODS: All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS). RESULTS: Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16-59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12-15) months were 80.1 ± 19.9 (0-100), 83.6 ± 19.2 (13.2-100), and 70.3 ± 27.0 (0-100), respectively. CONCLUSION: This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.

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