Thinking Out Loud by Residents in the OR: A Multipurpose Tool to Micromanage Teamwork and Navigate the Balance Between Competence and Seeking Guidance.

The quality of evidence supporting recommendations for conservative hip osteoarthritis management limits the treatment options available to patients prior to surgery. The care individuals receive prior to their eventual total hip replacement (THR) is likely to be variable and complex. These long-term care patterns remain undefined. A population-based retrospective case-control study using linked primary and secondary care data (CPRD Aurum/HES APC) in England was conducted to identify the longitudinal prevalence of surgical, pharmacological and non-pharmacological care strategies in the 10 years preceding THR between 2007 and 2021. 480,598 individuals (240,299 THR recipients matched 1:1 to non-recipients) were identified. Prevalence rate ratios (PRRs) modelled chronological changes in care, referencing the 6-month period immediately prior to surgery (or index date for controls). Conditional logistic regression estimated odds ratios (ORs) for THR adjusted for confounders. The prevalence of all pharmacological prescriptions increased over the 10-year observation period prior to THR, with an escalation in rates for opioids, oral NSAIDs and paracetamol starting at 24 months before surgery. All medication prescriptions were consistently higher in females across all time periods. The prevalence of sick leave and referrals for physiotherapy, hip imaging and pain clinic (non-pharmacological care) also increased. Hip injection prevalence increased from 0.03% at 12 months (6 to 12 month period) to 15.1% at 6 months (0 to 6 month period) pre-THR. Prescriptions for all analgesic sub-types, antidepressants, sick leave, and referrals for physiotherapy, pain clinic and hip imaging had increased odds of THR throughout the observation period. Strong opioid use in the final 6-month period represented the strongest association with surgery (OR 5.0 [95% CI 4.7, 5.2]). Younger patients consistently demonstrated a lower prevalence of medication prescriptions, and higher prevalence of sick leave issuance, relative to older groups. Escalating care is observed from 24 months prior to surgery among individuals who progress to THR. Prevalence of paracetamol and opioid prescriptions are high. Important age-related differences in care provision prior to THR relating to medication prescriptions and non-pharmacological interventions are present. This is accompanied by long-term elevated rates of sick leave in the working population.

Gunshot hip injuries present major reconstructive challenges due to contamination, retained projectiles, soft-tissue compromise, and variable bone loss. Total hip replacement (THR) in this setting carries increased risks of infection, instability, and technical failure. This study evaluated the clinical and radiological outcomes of THR following gunshot hip trauma using a structured, severity-based subclassification to inform reconstructive strategy. Thirty patients with gunshot hip injuries underwent surgical debridement followed by THR, performed as single-stage or staged procedures according to injury severity, contamination, and systemic condition. Injuries were categorized into three groups: structurally benign injuries; severe or neglected injuries with major bone or soft-tissue compromise; and complex abdominopelvic traversing injuries with visceral involvement. Reconstruction predominantly used cementless acetabular components, with selective use of long femoral stems, revision cups, dual-mobility designs, and bone grafts or porous metal augments. Clinical outcomes were assessed using the Harris Hip Score (HHS) and WOMAC index, and radiological evaluation focused on component stability and graft incorporation. A total of 30 patients were included: 11 in Group I (structurally benign injuries), 10 in Group II (severe or neglected injuries), and 9 in Group III (complex abdominopelvic traversing injuries). At a mean follow-up of 46 ± 10 (24-72) months, the mean Harris Hip Score (HHS) was 84 ± 10 and the mean WOMAC score was 19 ± 7. Operative complexity and blood loss increased with injury severity. Two-stage THR was required in 27% of Group I, 60% of Group II, and 100% of Group III. Radiographs demonstrated stable component fixation in all hips, with complete graft or augment incorporation within 6-12months. Postoperative complications occurred in five patients, predominantly in higher-severity groups. Functional outcomes were inversely related to injury severity. THR after gunshot hip injury achieved satisfactory mid-term functional and radiological outcomes in this single-center cohort. Staged reconstruction and advanced implant strategies appear beneficial in managing complex and contaminated injuries. These findings are descriptive and intended to inform clinical decision-making; further studies are required for external validation.

The mandatory collection of patient-reported outcome measures and the implementation of thresholds for hip and knee replacement surgery represent a growing international trend in value-based health-care policy. Our aim was to investigate whether the Oxford Hip Score (OHS) and Oxford Knee Score (OKS) can be used to accurately predict patient satisfaction, and to estimate thresholds to guide value-based health-care policy. All primary total hip replacements (THRs) and total knee replacements (TKRs) for osteoarthritis undertaken at a tertiary academic institution over a 6-year period were identified. Logistic regression models were used to evaluate preoperative and postoperative values for the OHS and OKS, and the change between them, as predictors of patient satisfaction. Optimal thresholds for both the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) were identified. A total of 1,429 THRs (mean patient age, 66.1 years, standard deviation [SD], 11.1 years; 819 [57.3%] female) and 1,079 TKRs (mean patient age, 68.3 years, SD, 8.4 years; 635 [58.9%] female) were included. For the postoperative OHS, thresholds of 35.5 (95% confidence interval [CI], 29.1 to 41.9) for the MCID and 36.5 (95% CI, 33.0 to 40.0) for the SCB were identified. For the postoperative OKS, thresholds of 30.5 (95% CI, 24.2 to 36.8) for the MCID and 38.5 (95% CI, 36.7 to 40.3) for the SCB were identified. For the change in OHS, thresholds of 19.5 (95% CI, 13.4 to 25.6) for the MCID and 20.5 (95% CI, 16.0 to 25.0) for the SCB were identified. For the change in OKS, thresholds of 13.5 (95% CI, 8.3 to 18.7) for the MCID and 14.5 (95% CI, 11.7 to 17.3) for the SCB were identified. Patients with worse preoperative function had higher thresholds. Preoperative Oxford scores were poor predictors of patient satisfaction. The thresholds for the postoperative Oxford scores and change scores may guide value-based health-care decision-making using the OHS and OKS. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

ABSTRACT Introduction Based on the principles of DRG, this study aimed to analyze the current status and existing problems in the clinical use of high-value medical consumables for certain specialized diseases in orthopedics and cardiovascular medicine, and propose application standards and targeted management strategies. Methods DRGs involving the use of high-value medical consumables in orthopedic total hip replacement and cardiovascular percutaneous coronary drug-eluting stent implantation were selected. Data from all patients within these groups were extracted, and the total hospitalization costs and high-value medical consumable costs were calculated for each patient. The cost structure of consumables was analyzed in relation to DRGs payment standards, and the related differences were evaluated. Results Within the same DRGs, the average proportion of high-value medical consumable costs in orthopedics and cardiovascular medicine were 43.12% and 62.02%, respectively. Compared to the DRG payment standards, a high percentage of cases in orthopedics and cardiovascular medicine exceeded the total cost, that rates of 81.56% and 77.41%, respectively, and were the main drivers of total hospitalization costs. Conclusion DRG can be used to evaluate the use of high-value medical consumables, which would lay the foundation for establishing reasonable standards for the proportion of consumable costs in specialized diseases.

Portable bone impact microindentation devices are a novel generation of diagnostic instruments allowing direct in vivo assessment of cortical bone strength. The assessment involves application of a single impact cycle on the bone and measurement of tissue response to the applied force in relation to a reference value adjusted for age and sex. Here, we report the case of a male patient, aged 66 years, who underwent a cementless right total hip replacement for the treatment of monolateral osteoarthritis, during which an incomplete spiral fracture of the proximal metaphysis of the femur occurred. The patient had no history of bone fragility, and preoperative evaluation by radiofrequency echographic multi spectrometry showed mild osteopenia at both the lumbar spine and the femoral neck, suggesting he had a relatively low risk of fragility fracture. Conversely, preoperative impact microindentation analysis, performed using the OsteoProbe device on the left tibia, showed extremely low bone resistance (average bone score of 58.4, versus the adult male normal value of 84.4 ± 7.0). Our case report suggests that bone strength evaluation by bone impact microindentation may potentially predict individual fracture risk not shown by bone mineral density assessment alone. KEY WORDS: Bone strength, bone impact microindentation, individual fragility fracture risk, diagnosis of bone fragility.

Identifying predictors for functional recovery following total hip replacement (THR) is essential for optimizing postoperative care. We aimed to identify preoperative factors affecting muscle recovery and functional outcomes 1-year after THR. This prospective observational study enrolled 103 patients scheduled for unilateral THR. Demographic data, body composition (dual-energy X-ray absorptiometry), and physical functions (grip strength, knee extension strength, and gait speed) were assessed preoperatively. Patients were reevaluated 1-year after surgery using the same parameters and patient-reported outcome measures (PROMs: modified Harris hip score, Western Ontario and McMaster Universities osteoarthritis index, EuroQol-5D). Of the initial cohort, 57 patients completed the 1-year follow-up (dropout rate: 44.7%). Multivariable linear regression analysis was performed to identify independent predictors. Significant improvements in muscle strength, mass, and PROMs were observed 1-year postoperatively. Multivariable analysis revealed that leg mass, preoperative grip strength, and appendicular skeletal mass, adjusted by body mass index, were significant independent predictors of postoperative PROMs. However, indices adjusted by height squared did not demonstrate consistent associations. Preoperative gait speed was also strongly correlated with functional outcomes. Patients undergoing THR experienced significant improvement in their muscle strength, mass, and functional recovery 1-year after the surgery. Skeletal muscle indices adjusted for body mass index or weight, rather than height2, were more consistently associated with surgical outcomes. These findings highlight the importance of the “load-to-capacity” ratio in weight-bearing joints.

The authors describe the development of a custom survey centered around the Three C's and Net Promoter Scores in a high-volume surgical private practice with limited resources and no research coordinator. This paper aims to examine whether an abbreviated survey can serve as a practical alternative to lengthy validated PROMs in tracking post-surgical recovery outcomes in a private practice setting. A retrospective, de-identified analysis was conducted on prospectively collected patient-reported outcome surveys administered via email preoperatively and 120-days postoperatively. Of 2,908 surveys administered, 101 patients undergoing four high-volume procedures (CTR, meniscectomy, TKR, hernia) with matched pre- and post-operative responses were included. Paired t-tests with Shapiro-Wilk normality testing were performed in R (version 4.3.2) at α = 0.001. In total, 2,908 surveys were administered between 2021 and 2024 with 719 pre-surgery responses collected and 439 responses to both pre- and post-surgery surveys. The highest volume cases were selected for analysis based on their high surgical volume (> 8 cases), clinical relevance to orthopedics, and their frequent association with post operative recovery function. Surgical patients undergoing Carpal Tunnel Release (CTR) (t = 4.04, p < 0.001), Meniscectomy (t = 3.46, p < 0.001), Total Knee Replacement (TKR) (t = 4.15, p < 0.001), and Total Hip Replacement (THR) (t = 4.71, p < 0.001) demonstrated significant improvements in post-surgical numerical pain score. Similar results were observed in functionality and disruptive stress scores. Researchers observed a calculated NPS of 88.2 of which 400 were promoters, 26 were passives, and 13 were detractors. The authors present this work as an initial signal study demonstrating that a brief and self-administered survey can capture statistically significant improvements in pain, functional difficulty, and psychological stress in a private practice setting with limited research infrastructure. While NPS and work metrics should not be used alone as a gauge of outcomes, they hold significant utility in conjunction with other patient reported outcomes. Reporting requirements by the Center for Medicare and Medicaid Services (CMS) require hospitals to collect pre surgery and one year post surgery (9-15 months) HOOS JR and KOOS JR scores for total joint replacement surgeries, with public reporting set for 2027 and reimbursement effects in 2028. These requirements underscore the need for streamlined solutions. As value-based care becomes a priority, practical strategies are needed to reduce the burden on providers and patients [1].

To evaluate the accuracy of 3 femoral craniocaudal radiographic techniques in assessment of femoral morphology using CT scans as the imaging modality of choice. Candidates were assessed from September 2024 through October 2025, and those with a normal orthopedic examination were enrolled. Extended limb, sitting position, and horizontal beam radiographs and CT scans were evaluated for frontal plane alignment, with the following measurements completed by 2 investigators independently: anatomic lateral distal femoral angle (aLDFA), mechanical lateral distal femoral angle, anatomic lateral proximal femoral angle, and mechanical lateral proximal femoral angle. Angles were statistically compared (P < .05) between groups, and interobserver variability was evaluated. Femoral morphology of 25 dogs (50 femora) with body weights ranging from 14 to 45 kg was assessed. Horizontal beam was most accurate for anatomic lateral proximal femoral angle, mechanical lateral proximal femoral angle, and aLDFA, whereas extended limb was most accurate for mechanical lateral distal femoral angle, with each showing no significant difference from CT. Sitting position was not the most accurate for any measurement. All measurements demonstrated high interobserver agreement (intraclass correlation coefficient > 0.8 for all parameters). Proximal and distal canine femoral morphology can be reliably measured by specific radiographic views in the absence of CT. In the absence of a CT scan, horizontal beam is recommended for accurate assessment of proximal femoral morphology in planning of total hip replacement and also demonstrated superiority when considering aLDFA measurements used for patellar luxation surgery planning.

Morse-type tapers at the head–stem junction in total hip replacements (THRs) provide many benefits to permit a successful surgical outcome. However, with the introduction of modular tapered devices comes complications associated with fluid ingress and motion at the interface that can cause fretting corrosion, which has been implicated in clinical failure. Increased surface roughness amplitude (Ra) and angular mismatch to ensure taper contact closer to the equator of the femoral head are design features introduced for use with ceramic heads but have been adopted by metal head couples. While increased surface roughness amplitude has been found to contribute to fretting corrosion, there is a distinct lack of systematic studies investigating the interactions between angular mismatch and Ra. This study measured the fretting corrosion and motion response of clinically representative samples, in part reference to ASTM F1875, when subjected to uniaxial incremental dynamic loading. The fretting corrosion response was measured in situ with an integrated three electrode electrochemical cell. Motion at the head–neck interface was measured with a bespoke motion measurement solution based on eddy-current principles which uses four sensors to allow motion to be fully characterised in three dimensions. Key findings from this study included a 5–10-fold increase in current measured in the increased roughness amplitude samples, suggesting an increased susceptibility to fretting corrosion without a corresponding increase in motion. The distal samples engaged around the opening of the taper interface and presented the lowest current measurements but most off-axis subsidence. Findings from this study indicate that optimisation of the taper interfaces in THR, in terms of fretting corrosion and motion, can be made and can be assessed using short-term preclinical tests.

Introduction:Accurate pre-operative templating is essential for successful total hip replacement (THR) to optimize component sizing and minimize complications. With the transition to digital radiography, traditional acetate templating faces compatibility challenges. This study evaluates the accuracy of acetate templates on magnified digital radiographs as a cost-effective alternative to digital templating software.Materials and Methods:A prospective observational study was conducted over 18 months on 25 patients undergoing uncemented total hip arthroplasty (THA) at a tertiary care center. Standardized anteroposterior pelvic radiographs with a 3 cm metal marker were obtained. Digital images were magnified to match the acetate template scale. Pre-operative predictions were compared with actual intraoperative acetabular cup sizes.Results:The mean patient age was 66.60 ± 5.74 years with male predominance (68%). Osteoarthritis was the most common indication (48%). Pre-operative templating predicted acetabular cup size with 88% exact match and 100% accuracy within ±2 mm. Most radiographs were rated good quality (64%). The most common cup sizes used were 50 mm and 54 mm.Conclusion:Acetate templating on digital radiographs provides highly accurate, reliable, and cost-effective prediction of acetabular cup size in THA. This method demonstrates excellent predictive power with 88% exact match and 100% accuracy within ±2 mm, making it a valuable tool, especially in resource-limited settings where advanced templating software may be unavailable.

Biomechanical evaluation of cemented femoral stem constructs with single and double cerclage stabilization of proximal fissures in canine cadaveric femora.

Hip osteoarthritis (HOA) is the most common hip joint disorder, accounting for approximately 27.9% of all cases of osteoarthritis (OA), often leading to total hip replacement (THR). In the last decades, femoroacetabular impingement (FAI) has been addressed as a significant etiological factor in the development of early-onset HOA, especially in young adults with non-dysplastic hips. FAI has been found to cause damage to all joint tissues, cartilage, labrum, and subchondral bone, thus underlining the importance of an early diagnosis and intervention to prevent progression to end-stage disease. This review aims to provide a comprehensive overview of the biochemical, morphological, and cellular alterations occurring in hip joint tissues in the presence of FAI. Understanding the early pathological changes is of crucial importance as they often precede radiographic signs of disease and may serve as valuable biomarkers for early detection and management of FAI and peri-arthritic conditions to delay or prevent the need for THR in younger populations.

Clinical outcomes and Quality-Adjusted Life Years (QALY) after femoral head fractures: A retrospective cohort study of 101 patients.

Introduction:Accurate orientation of the acetabular component in total hip arthroplasty (THA) is critical for restoration of hip biomechanics and prevention of complications such as instability, impingement, accelerated wear, and early implant failure. While computer-assisted navigation enhances accuracy, its routine use is limited by cost and availability. Anatomical landmarks, including the anterior acetabular notch (AAN) and transverse acetabular notch (TAN), may provide a reliable intraoperative reference for component positioning. This study evaluates the accuracy of acetabular cup placement using these landmarks with post-operative computed tomography (CT)-based assessment.Materials and Methods:A prospective observational study was conducted on 53 patients undergoing primary total hip replacement at a tertiary care center. Acetabular component positioning was guided intraoperatively using AAN for anteversion and TAN for abduction. Post-operative CT scans obtained on day 14 were used to measure cup orientation. Target alignment was defined according to Lewinnek’s safe zone (abduction 40° ± 10°, anteversion 15° ± 10°). Functional outcomes were assessed using the Harris Hip Score (HHS), and patients were followed up clinically and radiologically.Results:The mean post-operative acetabular cup abduction was 40.13° and anteversion was 16.29°, both within the defined safe zones. The mean HHS improved significantly from 37.42 preoperatively to 85.83 postoperatively, indicating substantial functional recovery. The mean error in cup positioning was markedly reduced post-operatively. No cases of dislocation or major complications were observed during the follow-up period.Conclusion:Simple anatomical landmarks can reliably guide acetabular cup placement in THA, offering a cost-effective alternative to intraoperative technology-assisted guidance methods like navigation, with comparable clinical outcomes.

Alzheimer's disease (AD) and total joint arthroplasty are prevalent and often concomitant in older adults, but an etiologic link is debated. Since wear particles are an inevitable side product of total joint arthroplasty (TJA), we hypothesized that older adults with TJA agglomerate higher-than-normal concentrations of implant alloy elements caused by the dissemination of debris from the implants, resulting in a pathological reaction. A cross-sectional analysis was conducted among 701 autopsied participants of an ongoing longitudinal cohort (Memory and Aging Project (MAP)) of whom postmortem neuropathologic data was available and implant-related metals (cobalt, titanium) were quantified in four brain regions by inductively coupled mass-spectrometry. MAP participants are enrolled without known dementia at baseline and followed annually for cognitive assessments using 19-test battery. In the analytical sample, 229 had TJA (total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty) and n = 472 had no total joint. Due to a higher likelihood of cobalt release in total hip arthroplasty, the TJA group was subdivided into a hip (n = 146) and a knee/shoulder (n = 83) group. We used regression and linear mixed-effects models, adjusted for demographics and apolipoprotein E ε4 status, to examine associations between metals, AD pathology and cognitive decline. Cobalt content of brain tissue was 8.9 % higher in the total hip arthroplasty group than in the no-TJA group (p = 0.003). Cobalt-containing particles were identified within brain tissue using scanning electron microscopy. In the inferior temporal cortex, cobalt was positively associated (p = 0.0004) and titanium was negatively associated (p = 0.038) with amyloid-beta load, but had no association with cognition. These results warrant monitoring the potential impact of metal implant debris on brain health. STATEMENT OF SIGNIFICANCE: This study is of great clinical significance because Alzheimer's disease (AD) and total joint arthroplasty (TJA)-the end-stage treatment of osteoarthritis-affect large and overlapping groups in our aging population. There is limited knowledge about the relationship between the prominent TJA implant metals cobalt and titanium and the pathogenesis of AD. This study shows that Co28Cr6Mo and Ti6Al4V implant alloy particles-most likely from a subset of total hip replacements with accelerated wear or tribocorrosion-can disseminate to the brain and be associated with increased cobalt and titanium concentrations. Cobalt was associated with greater AD pathology in the inferior-temporal cortex, even after correction for other known AD risk factors. However, there was no correlation with cognitive decline. Titanium was negatively associated with AD pathology, but titanium oxide appeared to be abundant in the brain from sources other than joint replacements.

Use of uncemented modular diaphyseal stems in salvage hip replacement after cut-out failure of cephalomedular fixation for extracapsular hip fractures. Monocentric series.

When conservative treatment of osteoarthritis is not effective, patients may undergo total joint replacement. Postoperative rehabilitation is a crucial component of recovery, and early rehabilitation plays a particularly important role in optimizing outcomes, with the aim of enabling patients to return to independence and work as soon as possible. The aim of this paper is to summarize the role of early rehabilitation after total knee and hip joint replacement, including its main goals, key components, optimal timing, potential risks, and the evidence comparing early with delayed rehabilitation. Current evidence indicates that early inpatient rehabilitation contributes to faster recovery of mobility, improved joint range of motion and muscle strength, fewer postoperative complications, and shorter hospital stays. Early outpatient rehabilitation initiated soon after discharge may further support recovery by increasing daily physical activity, improving joint mobility, and reducing rehabilitation costs. Although some studies report similar clinical outcomes between early and delayed physiotherapy, earlier initiation may allow patients to achieve comparable functional recovery sooner. Overall, early rehabilitation represents a safe and effective approach that should be integrated into standard postoperative care pathways.

Analyzing Bacterial Biofilm Formation on Cranioplasty Implants.

To characterize lumbar, sacral, and pelvic orientation in dogs in a standardized standing position, quantify interindividual variability, and assess relationships between pelvic geometry and acetabular orientation. The study was conducted from April 12, 2024, through November 20, 2025. Full-length lateral radiographs of the pelvic limbs were obtained in 17 standing, healthy, client-owned dogs using a standardized positioning technique. Composite images were generated from stitched radiographs. Spinal, pelvic, and hind limb axes were defined using anatomical landmarks, and their orientation relative to the horizontal plane was measured. Descriptive statistics were used to assess variability. Associations between standing acetabular orientation and pelvic parameters were evaluated using univariate linear regression. Standing acetabular orientation was markedly variable across dogs and did not correlate with other postural parameters. In contrast, the ischiopubic symphysis orientation exhibited the lowest interindividual variability and remained consistently nearly horizontal during standing. Lumbar spinal orientation showed substantially greater variability and did not consistently approximate a horizontal reference. The strongest association with standing acetabular orientation was observed for the acetabular-pubic angle (R2=0.70). Dogs maintain a nearly horizontal pelvic floor when standing but do not consistently maintain a horizontal lumbar spine. Standing acetabular orientation varies widely among dogs and cannot be reliably inferred from other postural parameters. The ischiopubic symphysis may represent a more reliable reference for estimating functional acetabular orientation than the lumbar spine and may improve preoperative planning of acetabular cup positioning in canine total hip replacement.