Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

Fracture neck of femur with delayed presentation in young patients can be a surgical challenge. Such scenarios are rare in the developed world but not uncommon in developing countries. To present the medium term results of open reduction and internal fixation accompanied by Quadratus Femoris muscle pedicle grafting in young patients who presented with a delay after sustaining a fracture neck of femur, 42 patients with fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. A posterior approach was used in all cases. The patients were advised not to bear weight until there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor. The age of the patients, predominantly male, ranged from 24 yrs to 50 yrs. Radiological union occurred on average at 6 months. Thirty-six patients proceeded to union; six patients had non-union and needed revision surgery. Complications included varus union in 9 cases; shortening greater than 2 cms occurred in 6 cases. Quadratus Femoris muscle pedicle grafting described by Meyer in the 1970s is useful in treating fracture neck of femur. Open reduction and internal fixation of the fracture neck of femur when supplemented with Quadratus Femoris muscle pedicle graft fixation promoted the union of fracture and preserved the head the femur

Objectives. to evaluate effect of a dedicated ward for patients with fractured neck of femur on length of acute bed stay and 30 days mortality rate. Design. a retrospective study of two different cohorts of patients with fractured neck of femur, one admitted to a general trauma/surgical ward and the second to a ward dedicated for patients with fractured neck of femur. Setting. a district general hospital affiliated to a University Teaching Foundation Trust. Cohorts. after application of inclusion and exclusion criteria, the first group includes 348 patients who have been diagnosed and admitted with a fractured neck of femur in a 12 months period starting from 01/01/2005. This group have been admitted to a general trauma/surgical ward. The second cohort includes 432 patients who have been diagnosed and admitted with a fractured neck of femur in a 12 months period starting from 01/05/2007. The second group have been admitted into a dedicated ward for patients with fractured neck of femur. Main outcome measures. Lengths of hospital stay in a orthopaedic bed and 30 days mortality rate as main outcome measures. Secondary outcome measures considered to be theatre waiting time and discharge destination improvement. Results. length of acute trauma bed stay has been reduced from 18.3 in the first group to 10.9 (P< 0.01) in the second group. Thirty days mortality rate did not show significant difference (10% vs. 10.8%). There were also some improvements in the secondary outcome measures including reduced theatre waiting time. Conclusion. (with acknowledge of study design limitations) our study has shown a dedicated ward for patients with fractured neck of femur, could shorten acute trauma bed stay, but did not have significant effect on 30 days mortality rate

Background. Patients with fractured neck of femur have historically received less attention than they deserve and have high morbidity and mortality. Literature suggests that speed to theatre reduces length of in-patient stay and complications. Methodology. Using patients' expressed needs as a basis to redesign the service, a multidisciplinary project team mapped the current process of admission, simulated and mapped an ideal process. This resulted in a fast admission process for patients with suspected fractured proximal femur. Paramedics call a trauma coordinator based on the specialist ward who meets the patient at the door of the Emergency Department, escorting them to X-ray. The fracture is confirmed remotely by an experienced surgeon using PACS. Patients are taken to an optimisation area in the theatre complex for consultant orthopaedic and anaesthetic assessment prior to surgery the same day (utilising spare time on elective and trauma lists), or early the following day. Fascia-iliaca blocks are provided by trauma coordinators to improve pain control and reduce sedative effects of opiates, aiding early mobilisation. Measures include time to theatre, length of stay, and patient experience. Meaningful mortality and morbidity data will become available later. Results. To date we have studied 79 patients (mean age 81 years) over ten weeks. Median time to theatre reduced from 42 hours to 22 hours (Range 2–78 hours). Median length of stay reduced from 10.5 days to 6 days (Range 2–20 days). Secondary improvements include list productivity, communication with relatives, patients' satisfaction. No increase in adverse events has been found and the anaesthetic team felt patients with chronic problems such as cardiac or renal failure were successfully operated on without unnecessary delays. Future Developments. This new process is a permanent change; within six months we will have 250 cases to present, with results of additional metrics

Objectives

Our aim to study the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures.

Re-positioning osteotomy in the treatment of un-united fracture neck of femur in young patients improves the biomechanical pre-conditions to promote bone union of the Pseudarthrosis. This operative procedure is the method of choice for Pseudarthrosis of the neck of the femur with a viable femoral head. It is also the method of choice in children and in adolescents even if there is avascular necrosis of the femoral head. The operative technique permits exacts planning, stable osteosynthesis both of the un-united fracture of the neck of the femur as well as the osteotomy and allows early mobilisation. In this series of 56 cases, only six (10%) had collapse of the femoral head due to avascular necrosis, six (10%) patients had severe pain in the hip and nine (16%) patients had severe restriction of hip movement. The overall success of the operation in this series was 84%

Fracture neck of femur (NOF) is a significant morbidity in the elderly patient and a significant burden on the healthcare system. Surgery induces a stress response resulting in hyperglycaemia, insulin resistance, and glucose intolerance (Diabetic triad). Furthermore, fasting pre operatively establishes a catabolic state. This diabetic state can last up to 3 weeks following surgery and therefore could be associated with the morbidity of diabetes. Methods. 26 patients with fracture NOF were enrolled in this preliminary study. Exclusion criteria included diabetics. Each underwent hemiarthroplasty or Dynamic Hip Screw fixation. Pre and post operative serum glucose levels were taken. 15 patients were selected to have pre and post operative serum insulin levels because of the expensive nature of the test. Results. Normal glucose range = 4-6 mmol/l. Normal insulin range = 17.8 – 173 pmol/l. 21 of 26 patients exhibited post operative hyperglycaemia (range 5 - 16.4mmol/l). 7 of 15 patients tested for insulin remained in our pilot study where pre and post insulin levels were obtained. Insulin is a technically difficult level to take and samples are easily discarded. 6 of 7 Insulin levels showed marked elevation post operatively (range 17.5 – 595.8). Conclusion. We are able to demonstrate that fracture NOF patients exhibit a postoperative hyperglycaemia and insulin resistance. Insulin levels were significantly elevated in 6 cases and established hyperinsulinaemia was present in 50% of cases. This pilot study determines that a post operative type 2 diabetic state is induced by surgery for fracture neck of femur, perhaps exacerbated by the catabolic state of fasting. If we are able to diminish this we may be able to mitigate morbidity associated with this diabetic state. This in turn may improve the morbidity and burden on our healthcare system

Introduction. Rising incidence of fracture neck of femur (NOF) are associated with rising geriatric population. Majority of patients are suffering from comorbid factors. Impaired renal function is a common comorbid factor and most of the time it is attributed to an acute renal impairment following the fracture and surgery. Objective of this study was to identify the effect of renal comorbid factors and their probable relative risk for a fracture and compare the results with Asian and European data. Specific objective was to identify a possibility of presence of pretraumatic subclinical chronic renal failure among fractured Sri Lankans. Methodology. Data were collected from fractured patients (N=200) and non-fracture sample for a period of one year. Variables studied were, serum calcium, serum phosphate, blood hemoglobin level, blood urea and serum creatinine. Data were analyzed using binary logistic and multiple regressions, principal component statistical technique using STATA software. Results. The logistic regression of renal co morbid factors with fracture showed that relative risk of occurrence of higher blood urea (> 8.2 mmol/L) in a NOF patient is 3.35 times higher(p value 0.012), relative risks of occurrence of high serum creatinine (> 120 µmol/L) is 3.17 times higher(P value-0.027), risk of low hemoglobin (Hb < 12) is 2.58(p value 0.005) times higher than a non-fracture patient even after adjustments for blood loss following fracture. Results were compared with the Asian and European data. Conclusions. Pretraumatic high blood urea, serum creatinine and low hemoglobin are associated with NOF Sri Lankan patients. Comparative Asian data shows higher figures in Sri Lanka. Studies in Nordic countries and Europe shows higher incidence of renal impairment in fracture neck of femur patients. Further studies are required to assess the presence of pretraumatic sub clinical chronic renal insufficiency in Sri Lanka and in European countries

To identify ideal screw placement for internal fixation of intra capsular fracture neck of femur to avoid fixation failures, 20 cadaveric bone measurements of the neck of femur in basal, midcervical and at sub capital regions were carried out using Vernial caliper and CT scan. Midcervical region of neck of femur measurements were further divided into upper half (Superior half) and Inferior half (Inferior Half). AP and Lateral view X-rays were obtained following three parallel screws placements in Femur neck:. Configuration 1: Triangular configuration where two screws are inferior and one superior. Configuration 2: Triangular configuration where two screws are placed superiorly and one screw inferiorly. Neck has wider diameter in the upper half of neck of femur than in the lower half in the mid cervical region. Placing two 7.0 mm cancellous screws (total 14 mm) in the lower half of the neck of femur, as widely practised, has more likely chances of not having purchase in the mid cervical region of the femur neck by at least one screw. Cannulated screws fixation carried out in reverse triangular configuration by placing two screws superiorly (superior-anterior and superior-posterior) and one screw inferiorly (inferior-central) has better fixation and avoids fixation failure. Reverse triangular configuration of fixation is also likely to support the weaker superior half of the neck which lacks stronger cortex and calcar part as in the inferior part of the neck. We also recommend placing a larger screw in the superior half of femur neck and a smaller screw in the inferior half in recon-–IM nail fixation, based upon our experiment result

Introduction. The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur at our institute. Methods. 412 patients (101 males/311 females) who underwent AO screws for fracture neck of femur over 5 years (2000 -2004) and followed-up for a minimum of 2 yrs formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic and GP letters was made. Age, residential placement, Garden's classification, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions were critically analysed. Post-op physiotherapy, proportion of patients sustaining contra-lateral fracture NOF and its management and mortality statistics were reviewed. Results. The mean age of patients was 68 yrs (range 18-96 yrs). Mean length of stay in hospital was 12.3 days (range2- 51 days) and mean time to operate from admission was 51 hrs (median 24 hrs). Second Surgery in form of hemiarthroplasty was required in 36, DHS in 7, Implant removal in 15 and Total hip replacement in 29 patients. Non-union occurred in 25 pts (7.93%)and avascular necrosis (AVN) in 61 Pts (19.36%) and overall 2 years mortality rate was 66 pts(16%). Conclusion. AVN and Non union was high in patients with displaced fractures, patients more than 80 yrs and patients with co-morbidities like Renal Failure, Diabetes Mellitus, Osteoporosis and Steroid intake etc. Outcome is influenced by complex interplay of multiple factors so we should treat the physiological age and not the chronological age

Background. In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Methods. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score. Results. In patients with an uncemented implant, 18-month revision (1.62% versus 0.57% (OR 2.90 [2.44–3.45], p< 0.001)), 4-year revision (2.45% vs 1.11% (OR 2.28 [1.45–3.65], p< 0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14 [1.08–1.21], p=0.028)) were significantly higher. Interestingly, 4-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45 [0.36–0.55], p< 0.001). No significant differences were seen in 30-day return to theatre, myocardial infarction, cerebrovascular event or 90-day pulmonary embolus. Discussion. In this national analysis of matched patients short and medium term revision rate, and perioperative chest infection was significantly higher in the uncemented group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty

Introduction

The rapidly expanding aging population in the UK are living longer than ever before, which is reflected by the rising number of relatively fit and healthy people that sustain fracture NOF (neck of femur). According to current NICE (National institute for health clinical excellence) guidelines a large proportion of fracture NOF patients meet the requirements to have a total hip arthroplasty (THA) for this injury. Dislocation rate of THA can be as high as 20% for patients with fracture NOF, which is a disastrous complication in these vulnerable patients. Numerous techniques have been adopted to minimise the risk of dislocation. The use of dual mobility (tripolar) acetabular components is one such strategy with a proven track record in the literature that is employed by surgeons at our institute.

Introduction

Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients.

The study aims to compare the short-term results of cemented and cementless total hip arthroplasty {THA} in active patients > 80 years of age with femoral neck fractures. Sixty two consecutive patients underwent THA during the study period {cemented -31 and cementless -31}. The mean age was 84 years {81–94 years}. Patients in both groups were comparable in their preoperative variables. Functional and radiological assessments were carried out using validated outcome measures. Complications were recorded. 51 patients were available for final analysis after accounting for deaths and cases lost in follow up. Of the 51 patients, 25 {49%} regained their pre-injury mobility status and 36 {70%} were community ambulant. Cementless THA was associated with significantly less surgical time, blood loss, transfusion rates and hospital stay. The overall mortality rates, complications, functional and radiological results were similar in both groups though the number of deaths in the perioperative period were significantly high in patients undergoing cemented THA. Satisfactory improvement in function with low reoperation rates can be achieved irrespective of the technique used. Complication rates are higher when compared to younger patients undergoing the procedure. Risks and benefits should be carefully assessed and explained before subjecting these patients to THA

Aims. Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. Methods. This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. Results. Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. Conclusion. Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus. Cite this article: Bone Joint Open 2020;1-7:392–397

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts. Cite this article: Bone Joint Open 2020;1-6:198–202

Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement

Vitamin D is vital for bone health because it assists in the absorption and utilisation of calcium. Vitamin D deficiency may predispose individuals to developing osteoporosis and subsequent osteoporotic fracture. There are various studies in elderly females with hip fractures correlating the low bone mineral density (BMD) with vitamin D levels. But very few studies have evaluated the influence on elderly males. Therefore this study was conducted. All male patients aged more than 50 years presenting to orthopaedic department, in JIPMER, Puducherry, with either fracture neck of femur or intertrochanteric fracture were included. Serum vitamin D level was assessed in them and BMD of both the hips was evaluated by DEXA scan. The vitamin D levels, T-scores, Z-scores were then analysed and correlated. Of the total 41 patients evaluated 21 (51%) had fracture neck of the femur and 20 (49%) patients had intertrochanteric fractures. We found that 11 (26.8%) patients had osteoporosis, 17 (41.5%) had osteopenia, and 13 (31.7%) had normal values. The mean value of total T-scores on fracture side was −1.55 and on no fracture side was −1.88. Among them 9 (22%) patients had vitamin D level <20 ng /mL, 15 (36%) had levels between 20ng–30ng/mL and 17 (41%) had >30ng/mL. Total T-score and Z-score on fracture side and no fracture side showed no correlation with vitamin D (p value >0.05) in these patients. We found significant osteoporosis in both neck and trochanteric regions on both fracture and no fracture sides, yet we had some patients with trochanteric fracture and some with neck fracture on only one side. In view of this other factors like mode of injury, velocity of injury, muscle wasting might have contributed significantly to the type of fracture and side involved. The BMD was found to be lower in patients with neck of femur fracture compared to intertrochanteric fracture, but no correlation was found between vitamin D and BMD scores at neck and trochanteric region. From this study it appears that there is no direct relationship between the vitamin D level and BMD in elderly males with hip fractures. It may emphasise that in male patients with hip fractures vitamin D may not have critical role in development of osteoporosis. The treatment of such patients with vitamin D supplements to prevent hip fractures is still debatable. However further studies in very large groups and controls may bring more light on this subject

INTRODUCTION. The Woodpecker pneumatic broaching system facilitates femoral preparation to achieve optimal primary fixation of the stem in direct anterior hip replacement using a standard operating table. The high-frequency axial impulses of the device reduce excess bone tension, intraoperative femoral fractures and overall operating time. The Woodpecker device provides uniformity and enhanced control while broaching, optimizing cortical contact between the femur and implant and thereby maximizing prosthetic axial stability and longevity. This study aims to describe a single surgeon's experience using the Woodpecker pneumatic broaching system in 649 cases of direct anterior approach (DAA) total hip arthroplasties to determine the device's safety and efficacy. METHODOLOGY. All consecutive patients undergoing elective anterior bikini total hip arthroplasties (THA) performed by a single surgeon between July 2013 and June 2018 were included. Patients undergoing a THA with the use of the Woodpecker device through a different surgical approach, revision THA or arthroplasties for a fractured neck of femur were excluded (n=219). The pneumatic device was used for broaching the femoral canal in all cases. Pre-operative and post-operative Harris Hip Scores (HHS) and post-operative radiographs were analyzed to identify femoral fractures and femoral component positioning at 6 weeks, 6 months and 12 months post-operative. Any intra-operative or post-operative surgical complications and component survivorship until most recent follow up were recorded in the clinical notes. RESULTS. A total of 649 patients (L THA=317, R THA=328 and bilateral=2) with a mean age of 69 (range 46–91yrs) and mean BMI of 28.3 (range = 18.4–44.0) underwent a DAA THA using a Woodpecker device were included in the study. Of these patients, 521 (80%) underwent uncemented and 128 (20%) underwent cemented femoral components. The time taken to broach the femur using Woodpecker broaching this system averaged 2.8 minutes (1.4 to 7.5 minutes) in both cemented and uncemented cases. In 91% of cases the templated broach size was achieved with the remaining 9% within +/− 1 size of the planned template. Radiographic analysis revealed 67.3% of the stems placed in 0–1.82 degrees of varus and 32.7% placed in 0–1.4 degrees of valgus. Average HHS were 24.4 pre-operatively, with drastic improvements shown at 6 weeks (80.95), 6 months (91.91) and 12 months (94.18) after surgery. Intraoperative femoral fractures occurred in three patients (0.4%) during trial reduction, a further three patients had periprosthetic post-operative fractures (0.4%) from falls, two patients had stem subsidence (0.3%) and a further two patients had wound infections (0.3%). At the most recent follow up, the survivorship of the acetabular component was 99.7% and the femoral component was 99.1%, with mean follow up of 2.9 years (0.5 to 5 years). No intraoperative or post-operative complications could be directly attributed to the Woodpecker broaching system. CONCLUSION. The pneumatic Woodpecker device is a safe and effective alternative tool in minimally invasive direct anterior hip replacement surgery for femoral broaching performed on a standard operating table. The skill and experience of the surgeon must be taken into consideration when utilizing new surgical devices