As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction. Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning. We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance. Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension. Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital

Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds. Operating room (OR) in and out times and surgical times were collected via EMR electronic and manual data extraction with verification. Multivariate statistical analyses were utilized with p<0.05 significant. Results. 1261 DA approach (43%) and 1647 posterior approach (57%) THAs were analyzed. Mean total OR time, including anesthesia and positioning, was greatest for hospital-based DA THAs (146 mins), followed by hospital posterior approach THAs (126.4 mins), ASC-based DA THAs (118.1 mins) and ASC posterior THAs (90.1 mins) (p<0.001). In multivariate analysis, compared to the optimal ASC posterior approach group, the total OR time predictive model added 31 minutes per ASC DA THA, 33 minutes per hospital posterior THA, and 56 minutes for hospital DA THA (p<0.001). Similar predictive effect was observed for surgical time, which added 18 minutes per ASC-based DA THA, 22 minutes for hospital posterior THA and 29 minutes for hospital DA THA (p<0.001). Conclusion. In the COVID era, efficiency should be enhanced to maximize patient access for elective procedures and facilitate the healthcare system financial recovery. Despite equivocal clinical results, DA approach THA consumes substantially more OR time when compared to the posterior approach in both the hospital and ASC setting

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). DAA THA is increasing, particularly among surgeons who have learned the technique during overseas fellowships. Whether DAA offers long-term clinical benefit is unclear. We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multi-centre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10-year Oxford Hip Score (OHS) and 10-year revision rates. 125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10-year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value <0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point post-op the OHS for DAA THA was 42.63, 42.10 for posterior THA and the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point. Whilst there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistically significant difference between the outcome measures or revision rates for the two approaches

Introduction: Despite the advances in total hip arthroplasty (THA), a dislocation after THA remains a disturbing complication. Dislocation after revision hip arthroplasty has been an underemphasized cause of failure in revision hip arthroplasty despite its higher dislocation rate than after primary THA. The effectiveness of posterior soft tissue repair in the posterior approach has been determined in primary THA. However, to the best of our knowledge, there are no reports dealing specifically with the effectiveness of posterior soft tissue repair in the posterior approach in revision hip arthroplasty. We investigated the influence of the posterior approach with soft tissue repair in revision hip arthroplasty by evaluating the rate of early posterior dislocation. Material and Method: Ninety-one patients (96 hips) who had undergone revision hip arthroplasty through the posterior approach were observed for 1 year or until dislocation occurred. Fifty-six revision hip arthroplasties were performed using the posterior approach with soft tissue repair technique. The results of these procedures were compared with those of 40 revision hip arthroplasties that had been performed using the posterior approach without soft tissue repair. Results: The dislocation rate of 10.0% in 40 hips using the posterior approach without soft tissue repair was reduced to 1.9% in 56 hips using the posterior approach with soft tissue repair. Discussion: Considering the results, it is clear that the posterior soft tissue repair in revision hip arthroplasty is clinically important for achieving a lower dislocation rate after revision hip arthroplasty. We suggest that to prevent dislocation after revision hip arthroplasty when a posterior approach is used, the posterior soft tissue, including the capsule and short external rotators, should be preserved and repaired as much as possible

Periprosthetic femur fracture (PFF) is a major complication following total hip arthroplasty (THA) that carries significant morbidity, mortality, and economic burden. Currently, uncemented stems are highly preferred in primary THA, but have been associated with higher risk of PFF compared to cemented stems. The use of collared stems in uncemented primary THA has shown promise in reducing PFF rates postoperatively. This retrospective study included 2,294 uncemented primary THAs using the posterior approach performed by two attending surgeons from January 2016 to December 2022. Both surgeons switched from a collarless femoral stem design to a collared design in May 2020. Data was collected regarding stem design, frequency of PFF, and requirement for revision surgery. Periprosthetic fractures were identified and confirmed using medical records and/or radiographic imaging. Fracture rates and percentages between collared and collarless stems were then analyzed. A Fisher's Exact Test was performed to determine if there was a significant association between collared and collarless stem use on PFF rates. A total of 2,294 uncemented primary THAs performed by 2 surgeons were eligible for analysis. 903 (39.4%) patients received a collared stem, and 1,391 (60.6%) patients received a collarless stem. In total, 14 (0.6%) PFFs occurred over the study period. There was 1 fracture (0.1%) out of 903 collared stems, and 13 fractures (0.9%) out of 1,391 collarless stems (p = 0.012). Collared stems were associated with a significant decrease in PFF rate when compared to collarless stems in uncemented primary THA. Future studies are encouraged to continue to investigate PFF and other complication rates with the use of a collared stem design

Range of Motion (ROM) assessments are routinely used during joint replacement to evaluate joint stability before, during and after surgery to ensure the effective restoration of patient biomechanics. This study aimed to quantify axial torque in the femur during ROM assessment in total hip arthroplasty to define performance criteria against which hip instruments can be verified. Longer term, this information may provide the ability to quantitatively assess joint stability, extending to quantitation of bone preparation and quality. Joint loads measured with strain-gaged instruments in five cadaveric femurs prepared using posterior approach were analysed. Variables such as surgeon-evaluator, trial offset and specimen leg and weight were used to define 13 individual setups and paired with surgeon appraisal of joint tension for each setup. Peak torque loads were then identified for specific motions within the ROM assessment. The largest torque measured in most setups was observed during maximum extension and external rotation of the joint, with a peak torque of 13Nm recorded in a specimen weighing 98kg. The largest torque range (19.4Nm) was also recorded in this specimen. Other motions within the trial reduction showed clear peaks in applied torque but with lower magnitude. Relationships between peak torque, torque range and specimen weight produced an R2 value greater than 0.65. The data indicated that key influencers of torsional loads during ROM were patient weight, joint tension and limb motion. This correlation with patient weight should be further investigated and highlights the need for population representation during cadaveric evaluation. Although this study considered a small sample size, consistent patterns were seen across several users and specimens. Follow-up studies should aim to increase the number of surgeon-evaluators and further vary specimen size and weight. Consideration should also be given to alternative surgical approaches such as the Direct Anterior Approach

Introduction. The hip hemiarthroplasty in posterior approach is a common surgical procedure at the femoral neck fractures in the elderly patients. However, the postoperative hip precautions to avoid the risk of dislocations are impeditive for early recovery after surgery. We used MIS posterior approach lately known as conjoined tendon preserving posterior (CPP) approach, considering its enhancement of joint stability, and examined the intraoperative and postoperative complications, retrospectively. Methods. We performed hip hemiarthroplasty using CPP approach in 30 patients, and hip hemiarthroplasty using conventional posterior approach in 30 patients, and both group using lateral position with the conventional posterior skin incision. The conjoined tendon (periformis, obturator internus, and superior/inferior gemellus tendon) was preserved and the obturator externus tendon was incised in CPP approach without any hip precautions postoperatively. The conjoined tendon was incised in conventional approach using hip abduction pillow postoperatively. Results. There was no difference between CPP approach group and conventional approach group in the mean age of patients (81.8 years, and 80.3 years, respectively), and in the mean operative time (68.8 minutes, and 64.9 minutes, respectively). In 4 cases of CPP approach, the avulsion fracture at femoral attachment of the conjoined tendon occured during hip reduction manoeuvres. No dislocations occured in both groups in the follow-up period (2 years). Discussion. Lately, the number of hip surgery in muscle sparing approach is increasing. However, in general, MIS approach induces the intraoperative complications, and requires the skillful procedure. The hip reduction manoeuvres would be more difficult in the CPP approach, than in conventional posterior approach, because the preserved conjoined tendon would inhibit hip reduction, considering those avulsion fractures of the femoral attachment. Nevertheless, CPP approach did not require no extended time compared to conventional approach, and no postoperative hip precautions. Due to these results, CPP approach could be a good MIS procedure including early recovery after surgery based on the enhancement of joint stability, excluding the difficulties in hip reduction manoeuvres. We could not show the difference in dislocation rate between two groups, because of small numbers. We are planning to increase the number of patients in the future study

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches. Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS. Aim: To find out the affect of surgical approach on oxford hip score. Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem and were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS. Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively. Conclusion: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posterior approach to the hip. We present the first systematic review and meta-analysis of these two approaches. Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hip arthroplasties were included. The mini-incision posterior approach was associated with an early improvement in Harris hip score of 1.8 points (P < 0.001), reduced operating time (5 minutes, P < 0.001), length of hospital stay (14 hours, P < 0.001), intraoperative and total blood loss (63 ml, P < 0.001 and 119 ml, P < 0.001 respectively). There were no statistically significant differences on the incidence of dislocation, nerve injury, infection or venous thromboembolic events. The minimally invasive posterior approach appears to provide a safe and acceptable alternative to the standard incision posterior approach

The purpose of this study was to investigate the influence of surgical approach on femoral stem version in THA. This was a retrospective database review of 830 THAs in 830 patients that had both preoperative and postoperative CT scans. All patients underwent staged bilateral THAs and received CT-based 3D planning on both sides. Stem version was measured in the second CT-scan and compared to the native neck axis measured in the first CT-scan, using the posterior condyles as the reference for both. Cases were performed by 104 surgeons using either a direct anterior (DAA, n=303) or posterior (PA, n=527) approach and one of four stem designs: quadrangular taper, calcar-guided short stem, flat taper and fit-and-fill. Sub-analyses investigated changes in version for low (≤5°), neutral (5–25°) and high (≥25°) native version subgroups and for the different implant types. Native version was not different between approaches (DAA = 12.6°, PA = 13.6°, p = 0.16). Overall, DAA stems were more anteverted relative to the native neck axis vs PA stems (5.9° vs 1.4°, p<0.001). This trend persisted in hips with high native version (3.2° vs -5.3°, p<0.01) and neutral native version (5.3° vs 1.3°, p<0.001), but did not reach significance in the low native version subgroup (8.9° vs 5.9°, p=0.13). Quadrangular taper, calcar-guided, and flat taper stem types had significantly more anteversion than native for DAA, while no differences were found for PA. Stems implanted with a direct anterior approach had more anteversion than those implanted with a posterior approach. The smaller surgical field, soft tissue tension and lack of a “tibial” vertical reference frame may contribute to this finding

Background:. Modified posterior approach and its effect on stability and functional outcome in total hip arthroplasty. Material & Methods:. A retrospective comparative evaluation was done to assess the functional outcome and rate of dislocation in 233 hips (Group A) operated before 2007 by convention posterior approach and 567 hips (Group B) were operated by modified posterior approach.(2007–2011) In this modified posterior approach technique, 2–3 stay sutures (non-absorbale Nylon) are applied in the piriformis tendon, short external rotator and proximal part of Quadratous muscle. Then a conjoint- myocapsular sleeve is raised by starting cutting (with cautery) linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus to expose and dislocate the head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured with same nonabsorbable Nylon at the lower part of tip of greater trochanter by passing through the bone with needle or by drilling the bone; lower part of the sleeve is tied with lateral trochanteric bone. Additional stability to repair was given by closing the tendinous part of the gluteus maximus by horizontal cross mattress sutures up its attachment to the proximal femoral shaft. Results:. All patients underwent cementless total hip arthroplasty; average Harris hip score at minimum 3.1 yr follow was 88.7 in Group B & 85.2 in Group B. Group B had only one dislocation while Group A had 12 dislocations (5%). Conclusion:. This technique provide enhanced stability and improve functional outcome

Introduction:. The routine use of posterior hip dislocation precautions is typically utilized postoperatively following total hip arthroplasty via a posterior surgical approach. This has included use of an abduction pillow and limiting adduction, internal rotation and flexion more than 90 degrees for a minimum of 6 weeks postoperatively. This may slow the course of rehabilitation, increase the length of hospital stay and the total cost of the procedure, and add additional anxiety to the patient. We conducted this study to see if posterior hip precautions are necessary after total hip arthroplasty via a posterior approach when the hip meets certain intraoperative criteria for stability. Methods and Materials:. All patients in our institute undergo routine hip stability testing during primary total hip arthroplasty via a posterior approach. Before October 2010, all of our primary total hip arthroplasty patients were placed on routine hip precautions. We stopped hip precautions in October 2010 for all the patients who were noted to meet hip stability criteria intraoperatively. We prospectively compared the consecutive patients who underwent this procedure without hip precautions with a retrospective control group of patients who had hip precautions. Results:. we had 650 patients in each group. In the case group, there was 1 postoperative dislocation (0.2%) within the first 3 months after surgery. In the control group (with hip precautions), 2 patients (0.3%) sustained hip dislocation within 3 months after surgery (p = 0.5). The mean hospital stay was 2.5 (0–11) days for the case group and 2.7 (1–9) days for the control group (p = 0.03). Patients in the case group were discharged to home more often compared to the control group (83.7% versus 83.4%), but the difference was not significant (p = 0.48). There was no difference in the Harris Hip score improvement between the two groups. Higher percentage of the patients in the case group received larger femoral head implant (35% versus 14%, p < 0.001) and elevated rim polyethylene liner (70% versus 57%, p < 0.001). Conclusion:. Intraoperative hip stability testing is necessary for all patients who undergo primary total hip arthroplasty via a posterior approach. If the hip is not stable intraoperatively, the surgeon should ensure that all sources of potential instability have been evaluated and managed. This may include implant sizing, implant position, and all sources of internal and external impingement. Use of a larger diameter head and elevated rim polyethylene may help with the stability of the hip. If the hip meets our stability criteria intraoperatively, we feel that formal hip precautions may not be necessary postoperatively

Introduction. Computer navigation systems are quite sophisticated intra-operative support systems for the precise placement of acetabular or femoral components in THA. However, few studies have addressed the clinical benefits derived from using a navigation system to achieve precise placement of the implants. The purpose of this study is to investigate the early dislocation rate of navigation-assisted primary THA through a posterior approach in order to clarify the short-term benefit of using a computer navigation system. Methods. We retrospectively reviewed the early dislocation rate (within 12 months after surgery) of 475 consecutive primary cementless or hybrid THAs with femoral head sizes ≦32mm performed via posterior approach. There were 85 men and 390 women, with a mean age of 60 years (17 to 88) at operation. Preoperative diagnoses included osteoarthritis in 384 hips, osteonecrosis in 45 hips, and others in 46 hips (ex. RA, trauma, infection, congenital disease). All THAs were planned using a 3D templating system based on the combined anteversion theory, performed by single surgeon through a posterior approach with repair of the posterior capsule, assisted by a CT-based surface matching type computer navigation system for cup implantation. All patients were directly followed up at least 1 year after surgery. We classified all 475 joints into four groups: normal or mildly deformed hips (Group A; 308 joints, ex. primary OA, Crowe group 1, osteonecrosis), moderately deformed hips (Group B; 97 joints, ex. Crowe group 2, protrusio acetabuli, Perthes like deformity), severely deformed hips (Group C; 53 joints, ex. Crowe group 3 or 4, ankylosis, fused hip), and neuromuscular and cognitive disorders (Group D; 17 joints), and examined the dislocation rate for each group. Results. We had eleven early dislocations, for an overall dislocation rate of 2.3% (11/475). All dislocations occurred posteriorly within 6 weeks after surgery. Three joints were Crowe group 4 dislocated hips, three were Charcot joints, two were Girdlestone hips after pyogenic arthritis, two was a Crowe group 1 hip, and one was osteonecrosis. All 11 cups were implanted within 5 degree of error from the preoperative planning, and all were placed within the Lewinnek safe zone. The dislocation rates according to group were 0.6% for group A (2/308), 0% for B (0/97), 9.4% for C (5/53), and 23.5% for D (4/17). Discussion. The use of computer navigation system in patients undergoing THA improves the precision of acetabular cup placement by decreasing the number of outliers, which may result in reducing the risk of dislocation. In this series, most dislocations occurred in the highly risky or rare condition cases in groups C or D. In such cases, precise and appropriate cup implantation assisted by the navigation system could not completely prevent dislocation because of the patients' specific special backgrounds. On the other hand, early dislocation was prevented for the normal/mild to moderately deformed joints such as those in groups A or B. Computer navigation system was effective for prevent early dislocation in the normal or mild to moderately deformed joints

The optimum approach for Total Hip Arthroplasty is hotly debated. Many surgeons, especially the newly trained, have been wary of the . posterior approach. because of higher reported rates of dislocation. We analysed 137 consecutive patients who underwent Primary Total Hip Replacement for Osteoarthritis during the first three years of practice of a newly appointed consultant with an interest in hip and knee arthroplasty. All surgeries were either performed by or under the direct supervision of the senior author. The posterior capsule and short external rotators were reattached to the Greater Trochanter as a routine. Data was gathered prospectively by proforma for all the patients, one at the time of operation and one each at 3 months and 12 months from the surgery. 4 patients died due to causes unrelated to their arthroplasty (2.9%) and 6 patients (4.3%) were lost to follow up. The patients were grouped into A, B and C depending on involvement of one hip, both hips and multiple joint diseases respectively and the patients were analysed for pain scores (1–6), function scores (1–6) and satisfaction levels (1–5) after the surgery. All the complications during and after surgery were noted, and special emphasis was laid on the incidence of dislocation, and factors contributing to it. The results were compared with the incidence reported in the literature for posterior and other approaches. The results were gratifying and were comparable with major series of Total Hip Replacement via the posterior approach. Only one patient (0.7%) had a dislocation. This occurred during the index admission when the patient sat down on a ward toilet without a raised toilet seat. The hip was reduced under General Anaesthesia and he had no problem thereafter. 122 patients (96%) had no pain or minimal pain not limiting the activity after the surgery but 5 patients (4%), 3 from Group C had activity related pain or pain at rest. 93 patients (73%) were walking without a stick after surgery and 34 patients (27%) were using a stick for extra safety. 5 patients (4%) had superficial infection which settled with antibiotics and one patient (0.7%) had deep infection which required a Revision hip surgery. 6 patients developed Deep Vein Thrombosis (4.7%) and one patient (0.7%) had Pulmonary Embolism but all the patients returned to good function after treatment. One patient (0.7%) developed transient Sciatic nerve palsy but recovered completely. We conclude that the posterior approach, already known to cause less blood loss and to allow optimum component positioning and alignment, is compatible with a low overall rate of early complications. Specifically, the dislocation rate is low and comparable with large series performed by approaches traditionally considered to carry a lower rate of dislocation

Modified posterior approach preserving short external rotators would be able to contribute greatly to prevent dislocation after total hip arthroplasty. We modified the posterior approach to the hip by preserving the external rotator muscles in order to enhance joint stability after total hip arthroplasty in patients with osteonecrosis of the femoral head. The aim of the this study was to determine the influence of external rotator preserving posterior approach in primary total hip replacement on early dislocation and clinical outcome. Three hundred sixty-four primary total hip replacements were divided into two groups based on how the external rotators were treated at surgery. External rotator preservation (Group 1, 165 hips) group was compared with reattachment (Group 2, 199 hips) group by evaluating the clinical and radiographic outcome at one year postoperative. Anteversion was significantly less in Group 1 as compared to Group 2 (P < 0.001). There was no significant difference in inclination between the groups (P > 0.05 in all comparisons). No dislocations were found in 165 hips with external rotator preservation whereas dislocations was noted in 11 (3.9%) in Groups 2, respectively. Group 1 had the higher mean Harris hip score (97.2±2.9 points) as compared with Group 2(94.9±3.4). The results of this study showed that external rotators could play an important role in preserving joint stability after total hip arthroplasty in patients with osteonecrosis of the femoral head. It can be implied that this modified posterior approach would be able to contribute greatly to prevention of dislocation, and improve clinical outcome after total hip arthroplasty

Introduction and Aims: Minimal Invasive Surgery (MIS) in THR surgery offers potential advantages over standard techniques. A user-friendly surgical technique has been developed via the posterior approach to the hip using a single six to eight centimetre incision, and requiring no special instrumentation other than three long Homan retractors of standard design. The technique has been used to date in 80 sequential non-obese patients undergoing both uncemented and cemented THRs. Method: Five cemented and 75 uncemented THR procedures were performed in the lateral position via a segment of the standard posterior approach incision, centred just behind the greater trochanter. The pre- and post-operative SF12, WOMAC, Harris hip score and Pain score were assessed prospectively; blood loss, theatre time and intra-operative and post-operative complications were charted, and compared with 40 matched standard incision patients. Cup and stem component positioning was assessed radiologically. The Body Mass Index (BMI) and the incision length were charted in each patient. The post-operative time to full weightbearing and stair climbing was charted. Results: There was no statistical difference in SF12, WOMAC, Harris hip score and Pain score in the two groups of patients. Blood loss was slightly reduced, but theatre time and intra-operative and post-operative complications were not increased. Cup and stem positioning on x-ray was not compromised. Immediate full weightbearing was allowed, including stair climbing post-operatively in all patients. Conclusion: MIS THR via the posterior approach is a safe and reproducible procedure, for both cemented and uncemented prostheses. It requires no special instrumentation or long learning phase for the experienced hip surgeon. Blood loss, theatre time and morbidity have not been increased, allowing a rapid discharge program as a routine

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores, VAS Pain, and Modified Harris Hip Scores (mHHS). Post-operatively, the DAA group had decreased length of stay [1.4 vs 2.2 days, p=0.0002] and increased distance walked on postoperative day 1 and 2 [95 vs 52 ft, p=0.011 and 251 vs. 163 ft, p=0.0004, respectively]. The DAA group had lower VAS pain scores [p<0.05] and required less day 1 and total narcotics [59 vs 80 morphine equivalents, p=0.029 and 138 vs 190, p=0.01, respectively]. The DAA cohort had improved PROMIS Physical Function scores and mHHS up to 5 weeks post- operatively. Anterior approach patients discontinued their assistive device 8 days earlier [p=0.01], left home 3 days earlier [p=0.001], and drove a car 5 days earlier [p=0.016] compared to posterior patients. Conclusion. Patients undergoing DAA THA had significantly shorter length of stay, improved mobilization, decreased narcotic requirements and improved inpatient VAS pain scores compared to mini-posterior THA. Furthermore, DAA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients. The significant improvement in physical function seen with DAA THA persisted up to 5 weeks post-operatively

Aim. To evaluate efficacy of a one stage posterior approach in decompression and eradication of infection in TB spine. Background. The classic operation for TB spine is anterior spine debridement. This involves a trans-thoracic, or retroperitoneal approach, thus increasing morbidity in an already compromised patient. The anterior procedure in the form of the Hong Kong operation is aimed at decompressing the spine, and debridement of necrotic tissue. If kyphosis is a major problem, its correction requires a posterior procedure, often not at the same sitting. Material and Method. A retrospective review of patients treated surgically for TB Spine during the time period 2009–2012. We examined the records of those patients that were treated by a posterior only approach. We took note of the demographics of the patients. We measured the efficacy of the decompression by measuring the pre op and post op neurologic status as measured by the Frankel grading. The efficacy of debridemide was assessed by measuring the preoperative and follow up ESR. Results. We identified 11 patients for review, 8 male and 3 females. 8 were HIV positive. The disease affected the thoracic spine. The average follow up was 12 months. There was good correction of the deformity and this was maintained throughout the follow up period. The ESR decreased in all the patients. Neurologic improvement was noted in 5 patients and no patients deteriorated. Statistical methods to quantify these changes were not significant because of the small numbers. Conclusion. In our environment a number of patients are immunocompromised by the HIV virus. A trans thoracic approach increases the morbidity in these patients. Effective decompression and debridement can be achieved by the posterior only approach. NO DISCLOSURES

An audit of a group of dislocations (7 out of 66 hip replacements) revealed a problem with the Charnley Golf Ball cup when used with the posterior approach. Sixty-six consecutive Charnley hip replacements in one institution by one surgeon using the posterior approach over a one year period are presented. The dislocation rate prior to the introduction of the Golf Ball cup was less than 1%. The overall dislocation rate after the introduction of the Golf Ball socket rose to 10.6%. Four patients suffered one dislocation, 2 patients suffered two dislocations and 1 patient suffered a dislocation and spontaneous reduction. Five patients were revisions hip replacements and 61 primary hip replacements. Two of the revisions dislocated. A study of the type of acetabular component type in this series showed there were 17 Wroblewski Angle Bore Sockets (WAB), 11 ogee long posterior wall sockets (OGLPW) and 38 golf ball (GB) sockets making a total of 66 hip replacements. Of the 17 patients with the WAB the dislocation rate was 0 %. Of the 11 OGLPW patients the dislocation rate was 0 %. However in the 38 patients with golf ball sockets the dislocation rate was 18% (7/38). All the dislocations were anterior. The acetabular component position was flexion 15–30 degrees (mode 30 degrees) and anteversion 0–10 degrees (mode 0 degrees). The numbers were not large enough to produce any statistical correlation. All femoral stems were set to 0 degrees anteversion. Following this audit we discontinued the use of the golf ball socket with the posterior approach and have had no further dislocations in primary hip replacement using either the OGLPW or the WAB sockets. Surgeons who use the posterior approach should be warned about the problems of a high anterior dislocation rate when using the Golf Ball cup