Aims. The purpose of this study is to evaluate early outcomes with the use of a smartphone-based exercise and educational care management system after total hip arthroplasty (THA) and demonstrate decreased use of in-person physiotherapy (PT). Methods. A multicentre, prospective randomized controlled trial was conducted to evaluate a smartphone-based care platform for primary THA. Patients randomized to the control group (198) received the institution’s standard of care. Those randomized to the treatment group (167) were provided with a smartwatch and smartphone application. PT use, THA complications, readmissions, emergency department/urgent care visits, and physician office visits were evaluated. Outcome scores include the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), health-related quality-of-life EuroQol five-dimension five-level score (EQ-5D-5L), single leg stance (SLS) test, and the Timed Up and Go (TUG) test. Results. The control group was significantly younger by a mean 3.0 years (SD 9.8 for control, 10.4 for treatment group; p = 0.007), but there were no significant differences between groups in BMI, sex, or preoperative diagnosis. Postoperative PT use was significantly lower in the treatment group (34%) than in the control group (55.4%; p = 0.001). There were no statistically significant differences in complications, readmissions, or outpatient visits. The 90-day outcomes showed no significant differences in mean hip flexion between controls (101° (SD 10.8)) and treatment (100° (SD 11.3); p = 0.507) groups. The HOOS, JR scores were not significantly different between control group (73 points (SD 13.8)) and treatment group (73.6 points (SD 13); p = 0.660). Mean 30-day SLS time was 22.9 seconds (SD 19.8) in the control group and 20.7 seconds (SD 19.5) in the treatment group (p = 0.342). Mean TUG time was 11.8 seconds (SD 5.1) for the control group and 11.9 (SD 5) seconds for the treatment group (p = 0.859). Conclusion. The use of the smartphone care management system demonstrated similar early outcomes to those achieved using traditional care models, along with a significant decrease in PT use. Noninferiority was demonstrated with regard to complications, readmissions, and ED and urgent care visits. This technology allows patients to rehabilitate on a more flexible schedule and avoid unnecessary healthcare visits, as well as potentially reducing overall healthcare costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):91–97

Background. The purpose of this study is to evaluate the early outcomes with the use of a smartphone-based exercise and educational platform after primary total hip arthroplasty compared to a standard of care control group. Methods. A multicenter prospective randomized control trial was conducted evaluating the use of the mymobility smartphone-based care platform for primary total hip arthroplasty (THA). Patients randomized to the control group (198 patients) received the respective institution's standard of care. Those randomized to mymobility treatment group (167 patients) were provided an Apple Watch and mymobility smartphone application. The application provides pre and postoperative educational content, video directed exercise programs as well as tracks the patient's activity. Patients in the treatment group were not initially prescribed physical therapy, but could be if their surgeon deemed it necessary. Early outcomes assessed included 90-day hip range of motion, HOOS JR scores, 30-day single leg stance (SLS) and time up and go (TUG) test. We also evaluated PT utilization, THA complications associated with readmissions, ER visits not associated with readmissions, urgent care (non standard of care) visits, and physician office visits. Outcome scores include HOOS-Jr, EQ-5D-5L, single stance (SLS), Timed up and go (TUG). Satisfaction scores for the procedure and the mymobility study group were also recorded. Results. The control group was significantly younger by 3.0 years (p=0.007), but no significant difference between groups in BMI, gender or preoperative diagnosis. Postoperative PT utilization was statistically lower in the mymobility group. (P=.001). There were no statistically significant differences in complications, readmissions, or office visits. The 90-day outcomes showed no significant differences in hip flexion between controls (101.3±10.9) and mymobility (99.8 ±12) (p=0.34). HOOS JR scores were not significantly different between control group (84 ±14.5) and mymobility group (81 ±13) (p=0.15). Mean 30-day SLS time was 22.5 ±20 sec in the control group and 19.8 ±19 sec in the mymobility group (p=0.25). Mean TUG time was 14.1 ±27.4 sec for control group and 16.1 ±43.3 sec for my mobility group (p=0.7). Conclusion. The use of the mymobility care platform demonstrated similar early outcomes to traditional care models. This study showed a significant decrease in PTA utilization. Initial findings demonstrated non inferiority of the mymobility platform with regards to complications, readmissions, emergency room and urgent care visits. Strengths of this study include randomized, multicentered study design. Both groups were balanced except for age. Weakness of this study is the lack of preoperative functional testing which may influence postoperative single stance. This technology allows patients to rehabilitate on a more flexible schedule, avoid unnecessary healthcare visits as well as potentially decrease overall healthcare costs

Patients may be able to return to higher level activities following hip arthroplasty with modern techniques and prostheses, but the Oxford hip score, the standard PROM used by the NJS exhibits severe skew and kurtosis. The commonest score is 48/48. Most patients score above 40 preventing any discrimination between approaches or prostheses. We therefore sought both subjective and objective metrics which were relevant and valid without skew or high kurtosis in postoperative patients. The Metabolic Equivalent of Task (MET) reports energy usage in kcal/min burnt across a range of activities, condensed into a score of 0–25. A MET over 8 is considered ‘conditioning exercise’ tethered to life expectancy. A 2 point difference in average MET is considered a clinically relevant difference. Walking speed is a simple valid metric tethered to life expectancy, with a 0.1m/sec difference in walking speed equates to a clinically important difference. Oxford Hip Score (OHS), and the MET were prospectively recorded in 221 primary hip arthroplasty procedures pre-operatively and at 1-year using a web based application. Pre and postoperative Gait analysis was undertaken on a subgroup of 34 patients, in comparison with age and sex matched controls. Post-operatively, the OHS demonstrated significant skewed distributions with ceiling effects of 41% scoring 48/48. The MET was normally distributed around a mean of 10.3, with a standard deviation of 3.8 and no ceiling effect. Walking speed was normally distributed around a mean of 1.8m/sec, with a standard deviation was 0.15 m/sec. The MET is a simple patient reported score, which is normally distributed in patients following hip arthroplasty, around a mean of 10.3 with a standard deviation of 3.8. This valid activity metric correlates well with fast walking speed. This is also normally distributed with a standard deviation of over 0.1m/sec confirming low kurtosis. These simple measures have face validity: undertaking less active pastimes and being unable to keep up with other walkers are obviously inadvisable. The normal kurtosis of these metrics suggest that they may able to detect clinically relevant differences in outcome which are undetectable with commonly used PROMs. For surgeons developing less invasive approaches or using novel stems, these measures may detect clinically important improvements undetectable by the Oxford Hip Score

Aims. To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. Results. In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four ‘final product analysis’ (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. Conclusion. Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre. Cite this article: Bone Joint Open 2020;1-9:594–604

Orthopaedic surgical hoods rely on an intrinsic fan to force clean external air over the wearer and allow potentially contaminated and expired air to flow down and away from the surgical field. Carbon dioxide (CO. 2. ) is produced through aerobic metabolism and can potentially accumulate inside the hood. Levels above 2500ppm have been shown to affect cognitive and practical function in flight simulator studies. Maximum Health and Safety Executive (HSE) 8-hour exposure limit is 5000ppm There is a paucity of data on real-world CO. 2. levels experienced during arthroplasty surgery whilst wearing a hood. CO. 2. levels were continuously recorded during 31 elective arthroplasties, both primary and revision. Data was collected for surgeon and assistant. Data was recorded at 0.5Hz throughout the procedure utilising a Bluetooth CO. 2. detector, worn inside a Stryker Flyte. ™. surgical helmet worn with a toga gown. Four surgeons contributed real time data to the study. This data was augmented with experimental data, investigating varying fan speeds and activity levels. Median operative duration was 82 minutes (range 36–207). The average CO. 2. level across all procedures was 2952ppm, with 22 of the cases having a mean above 2500ppm, but none having a mean above 5000ppm. For each procedure, the time spent above 2500 and 5000 ppm was calculated, with the average being 68.4 % and 5.6% respectively. The experimental data demonstrated higher CO. 2. levels with lower fan speed, and at higher activity levels, and levels exceeding 15000 ppm during gentle exercise. During operative cases, low fan speed cases did have a marginally higher mean CO. 2. value than high fan speed (3033.02 and 2903.56 respectively) but the small numbers of cases (n=10) where this data was captured limit the relevance of this difference. The use of surgical helmets for elective orthopaedic surgery, can results in CO. 2. levels regularly rising to a point which may affect cognitive function. This study recommends the use of a higher fan speed where possible to minimise the risk of such CO. 2. levels, and recommends further research in this area

Aims. Cementless acetabular components rely on press-fit fixation for initial stability. In certain cases, initial stability is more difficult to obtain (such as during revision). No current study evaluates how a surgeon’s impaction technique (mallet mass, mallet velocity, and number of strikes) may affect component fixation. This study seeks to answer the following research questions: 1) how does impaction technique affect a) bone strain generation and deterioration (and hence implant stability) and b) seating in different density bones?; and 2) can an impaction technique be recommended to minimize risk of implant loosening while ensuring seating of the acetabular component?. Methods. A custom drop tower was used to simulate surgical strikes seating acetabular components into synthetic bone. Strike velocity and drop mass were varied. Synthetic bone strain was measured using strain gauges and stability was assessed via push-out tests. Polar gap was measured using optical trackers. Results. A phenomenon of strain deterioration was identified if an excessive number of strikes was used to seat a component. This effect was most pronounced in low-density bone at high strike velocities. Polar gap was reduced with increasing strike mass and velocity. Conclusion. A high mallet mass with low strike velocity resulted in satisfactory implant stability and polar gap, while minimizing the risk of losing stability due to over-striking. Extreme caution not to over-strike must be exercised when using high velocity strikes in low-density bone for any mallet mass. Cite this article: Bone Joint Res 2020;9(7):386–393

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Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

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The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

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To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia.

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The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR.

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Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA.

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In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance.

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This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening.

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Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty.

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The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.

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This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures.

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Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

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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.

The SPAIRE technique (Spare Piriformis And Internus, Repair Externus) involves a muscle sparing mini-posterior approach to the hip. Evidence will be prevented that the principle function of the “short external rotator” muscle group is primarily as an abductor and extensor of the flexed hip and has a profound influenced on weight bearing rising and propulsive motions; also that details of the insertions of the piriformis tendon and conjoint insertion of obturator internus and the gemelli (the Quadriceps Coxa) have previously been poorly appreciated. We have developed a surgical technique (SPAIRE) during which the only tendon released, and subsequently repaired, is obturator externus. The author has carried out the SPAIRE technique for all routine hip arthroplasties for the last 18 months. This cohort has been compared with a matched control group for a comprehensive array of outcome measures. Results show no disadvantage of using the technique. On-table stability is so impressive that when the SPAIRE technique has been used no postoperative restrictions whatsoever are placed on the patient who is immediately encouraged to exercise the hip through a full excursion of movement. Fewer tendons are damaged using the SPAIRE technique than any other approach to the hip including Direct Anterior and Direct Superior approaches. Randomised prospective studies are on-going using objective measurements of Gait and muscle power as well as functional and patient reported outcomes to prove benefit of the SPAIRE technique. For hemiarthroplasty cases a separate RCT is being undertaken comparing the SPAIRE technique with a direct lateral approach. It is believed that this technique may become the default technique for hemi- and total- hip arthroplasty through a posterior approach and for all hip fracture arthroplasty cases

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Adverse spinal motion or balance (spine mobility) and adverse pelvic mobility, in combination, are often referred to as adverse spinopelvic mobility (SPM). A stiff lumbar spine, large posterior standing pelvic tilt, and severe sagittal spinal deformity have been identified as risk factors for increased hip instability. Adverse SPM can create functional malposition of the acetabular components and hence is an instability risk. Adverse pelvic mobility is often, but not always, associated with abnormal spinal motion parameters. Dislocation rates for dual-mobility articulations (DMAs) have been reported to be between 0% and 1.1%. The aim of this study was to determine the early survivorship from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of patients with adverse SPM who received a DMA.