Clinical Outcome following Management of Severe Osteomyelitis due to Pin Site Infection.

Aim: This study has investigated cases of pin site infection (PSI) which required surgery for persistent osteomyelitis (OM) despite pin removal. Materials and methods: Patients requiring surgery for OM after PSI between 2011 and 2021 were included in this retrospective cohort study. Single-stage surgery was performed in accordance with a protocol at one institution. This involved deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. A successful outcome was defined as an infection-free interval of at least 24 months following surgery. Results: Twenty-seven patients were identified (the sites were 22 tibias, 2 humeri, 2 calcanei, 1 radius); about 85% of them were males with a median age of 53.9 years. The majority of infections (21/27) followed fracture treatment. Fifteen patients were classified as BACH uncomplicated and 12 were BACH complex. Staphylococci were the most common pathogens, polymicrobial infections were detected in five cases (19%). Seven patients required flap coverage which was performed in the same operation.After a median of 3.99 years (2.00-8.05) follow-up, all patients remained infection free at the site of the former OM. Wound leakage after local antibiotic treatment was seen in 3/27 (11.1%) cases but did not require further treatment. Conclusion: Osteomyelitis after PSI is uncommon but has major implications for the patient as 7 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections were treated in accordance with a protocol and were not managed simply by curettage. All patients treated in this manner remained infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective. Clinical significance: Pin site infection is a very common complication in external fixation. The sequela of a chronic pin site OM is rare but the implications to the patient are huge. In this series, more than a quarter of patients required flap coverage as part of the treatment of the deep infection. How to cite this article: Frank FA, Pomeroy E, Hotchen AJ, et al. Clinical Outcome following Management of Severe Osteomyelitis due to Pin Site Infection. Strategies Trauma Limb Reconstr 2024;19(1):21-25.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty.

BACKGROUND: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. AIMS: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years. METHODS: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. RESULTS: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. CONCLUSIONS: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

No Difference in Subsidence Between Modern Monoblock and Modular Titanium Fluted Tapered Femoral Stems.

BACKGROUND: Subsidence remains a concern when utilizing tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability, and failure to obtain osseointegration. This study aims to compare stem subsidence across 3 modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or "scratch fit" on subsidence, as well as the role of intraoperative imaging in maximizing bicortical contact and preventing stem subsidence. METHODS: A retrospective review of 271 hip arthroplasties utilizing modern TFT stems at a single institution was performed. Three stem designs were included in the analysis: 1 monoblock TFT stem (n = 91) and 2 modular TFT stems (n = 90; n = 90). Patient demographics, Paprosky femoral bone loss classification, bicortical contact, utilization of intraoperative imaging, and stem subsidence (comparison of initial postoperative radiograph to the latest follow-up radiograph-minimum 3 months) were recorded. RESULTS: There was no statistically significant difference in overall subsidence (P = .191) or the incidence of subsidence >5 millimeters between stems (P = .126). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was associated with reduced subsidence (P = .004). Intraoperative imaging was used in 46.5% (126 of 271) of cases; this was not correlated with bicortical contact (P = .673) or subsidence (P = .521). CONCLUSION: All 3 modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate.

The Role of a Seven-Day Physiotherapy Service in Reducing Length of Stay and Improving Cost-Effectiveness in Arthroplasty Surgery.

Background Length of hospital stay post hip and knee arthroplasty is influenced by several factors, including gender, home circumstances and underlying diagnosis. Due to increasing demand for hip and knee arthroplasty, elective units, operating within already stressed healthcare systems, must identify methods of increasing efficiency and capacity. We sought to establish whether the lack of a seven-day inpatient physiotherapy service resulted in an increased hospital length of stay post primary hip and knee arthroplasty. Methods One hundred consecutive joint replacements (50 total hip replacements and 50 total knee replacements (TKRs)), performed in our institution from January to February 2020, were assessed. The length of stay for the cohort was analysed, and delays to discharge were identified. T-test was used to analyse the difference in length of stay based on the day of the week the surgery was performed. Results The mean length of stay for all primary hip and knee arthroplasties was 3.42 (standard deviation (SD): 1.62) days. Hip and knee arthroplasties performed on a Thursday or Friday had a significantly higher average length of stay than those performed on Monday, Tuesday or Wednesday (3.89 versus 3.02, p=0.006). We calculated that operating a six-day versus seven-day physiotherapy service in our unit cost 318 bed days per year equating to €986,535. Conclusion Length of stay post total hip and knee arthroplasty in our unit is significantly affected by the day of the week that surgery is performed. Elective orthopaedic units should consider all means of maximising efficiency and lowering costs given the future challenges in service provision.

Distal radius fracture fixation using WALANT versus general and regional anesthesia: A systematic review and meta-analysis.

BACKGROUND: WALANT (wide-awake local anaesthetic no tourniquet) has become a popular technique in upper limb surgery including distal radius fracture fixation. The purpose of this systematic review and meta-analysis is to assess the effectiveness of the WALANT technique in distal radius fracture fixation, and to compare it to both general and regional anaesthesia. METHODS: Pubmed, Embase, and Scopus databases were searched on 26/06/21 according to the PRISMA guidelines with the following search terms: radius, WALANT, "local anesthetic", wide-awake surgery. All studies comparing WALANT with other forms of anaesthesia for distal radius fracture fixation were included. RESULTS: 110 articles were identified, six studies (410 patients) were included, 164 of these patients were in the WALANT group. Two patients (1.2%) in the WALANT group and seven (6.5%) in the regional anaesthesia group required conversion to general anaesthesia. There was no statistically significant difference in post-operative complications, intra-operative VAS pain scores, operative times, functional or radiological outcomes. A statistically significant 8.6 mls increase in pooled mean blood loss in the WALANT group was noted (p = 0.02) although the clinical significance of this is doubtful. CONCLUSION: The WALANT technique for distal radius fracture fixation is non-inferior to regional and general anaesthesia. It is a safe and effective technique that surgeons may consider utilising, especially for patients not suitable for general anaesthetic or in centres in which there is a lack of access to specialist anaesthetic equipment and care.

Subsidence of monoblock and modular titanium fluted tapered stems in revision hip arthroplasty: A retrospective multicentre comparison study.

Background: Tapered, fluted, titanium (TFT) stems have shown good clinical outcomes in revision total hip arthroplasty (rTHA), however concerns exist regarding early subsidence. This study compares subsidence between a modern monoblock 3-degree and a modular 2-degree TFT stem in rTHA. Methods: A retrospective, international multicentre comparative study was conducted including 64 rTHA in 63 patients. A monoblock TFT stem was used in 37 cases and a modular TFT stem was used in 27 cases. Patient demographics, Paprosky femoral bone loss classification, bicortical contact and stem subsidence were recorded at minimum four week follow up. Results: There was no statistically significant difference in overall subsidence (p = 0.318) or the rate of subsidence >10 mm between stems. Mean subsidence was 2.13 mm in the monoblock group and 3.15 mm in the modular group. Two stems subsided >10 mm: one in each group. There was no difference in bicortical contact between groups (p = 0.98). No re-revisions were performed. Conclusions: We found no difference in subsidence between the two stems. Surgeons may consider the use of monoblock stems in rTHA as they have comparably low rates of subsidence and eliminate the small but potentially catastrophic risk of implant fracture at modular junctions associated with modular stems.

Cement Mantle Quality and Stem Alignment in Cemented Collarless Polished Tapered Stems Implanted via the Direct Anterior and Direct Lateral Approaches: A Single Institution Experience.

BACKGROUND: The aim of this study was to compare the stem alignment and the quality of cement mantle of collarless polished tapered cemented stems inserted through the direct anterior approach (DAA) and the direct lateral approach (DLA). METHODS: A comparative retrospective study of 232 hybrid total hip arthroplasties using a cemented collarless polished tapered stem through either the DAA (n = 147) or DLA (n = 85) was performed. Radiographic evaluation included stem alignment, cement mantle quality, and cement mantle thickness. RESULTS: On anteroposterior radiographs, stems implanted through the DLA were more likely to be in neutral alignment, than those implanted through the DAA (83.5%[n = 71] versus 71.4% [n = 105]; P = <.001). No difference between approaches was noted for stem alignment on lateral radiographs or cement mantle quality. Multivariate analysis revealed factors associated with suboptimal cement mantle and included Dorr type B or C femur as well as male gender. A mean cement mantle thickness ≥2mm was achieved in all Gruen zones for both approaches. CONCLUSION: In our series, the DAA was associated with a higher incidence of coronal plane stem malalignment compared to the DLA when using cemented tapered polished femoral components for total hip arthroplasty. No difference in lateral stem alignment or cement mantle quality was found.

Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement With Standardized Versus Procedure-Specific Consent Forms.

OBJECTIVES: Informed consent plays a pivotal role in the operative process, and surgeons have an ethical and legal obligation to provide patients with information to allow for shared decision-making. Unfortunately, patient recall after the consent process is frequently poor. This study aims to evaluate the effect of procedure-specific consent forms on patient's recall four weeks after total hip replacement (THR). METHODS: This is a prospective study using a posttest-only control group design. Sixty adult patients undergoing total hip replacement were allocated to be consented using either the generic or the surgery-specific consent form. Four weeks after surgery, a phone interview was conducted to assess patient's recall of risk of surgical complications. RESULTS: Patient demographic characteristics and educational attainment were similar in both groups. There was a statistically significant increase in the mean number of risks recalled in the study group at 1.43 compared with 0.67 in the control group (P = 0.0131). CONCLUSIONS: Consent is a complex process, and obtaining informed consent is far from straightforward. A statistically significant improvement in patient's recall with the use of procedure-specific consent forms was identified, and based on this, we would advocate their use. However, overall patient recall in both groups was poor. We believe that improving the quality of informed consent may require the sum of small gains, and the use of procedure-specific consent forms may aid in this regard.

Perioperative Mortality After Cemented or Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures-A Systematic Review and Meta-analysis.

BACKGROUND: Debate surrounds the use of cemented or uncemented prostheses for the treatment of displaced femoral neck fractures (FNF). Many guidelines recommend the use of the cemented hemiarthroplasty (CHA). Proponents of CHA point out the increased re-operation rate while proponents of uncemented hemiarthroplasty (HA) highlight the increased mortality rate in the perioperative period. The aim of this study was to systematically review the literature to evaluate perioperative mortality after HA for displaced FNFs. METHODS: A systematic review and meta-analysis was performed of MEDLINE, Cochrane Library, and Embase databases evaluating perioperative mortality after HA for displaced FNFs. Randomized control trials and observational studies were included comparing current-generation stem designs. A meta-analysis was performed on studies that directly compared the different modes of fixation. RESULTS: Twenty-two studies were included (seven randomized control trials and 15 observational studies), with a total of 183,167 HAs for treatment of a displaced FNF. Fourteen studies were included in the meta-analysis. There was a higher cumulative odds of death within the first 48 hours in those with CHA compared with uncemented HA (OR: 1.64; 95% CI: 1.35, 2.00; P ≤ .01). No difference was found in mortality at 7 days, 30 days, and one year. CONCLUSION: CHA is associated with an increased mortality rate within the first two days of surgery with no difference at 7 days, 30 days, and one year. Surgeons should consider tailoring their stem choice based on the physiological status of the patient when planning HA for FNFs. Techniques to reduce the risk of bone cement implantation syndrome should be used.

A Systematic Review of Total Knee Arthroplasty in Neurologic Conditions: Survivorship, Complications, and Surgical Considerations.

BACKGROUND: Patients with neurologic disorders present a unique set of challenges for knee surgeons because of contractures, muscle weakness, spasticity, and ligament instability. The primary purpose of this review was to report the outcomes of total knee arthroplasty (TKA) in these patients, including survivorship, complications, and surgical considerations. METHODS: We performed a systematic review of articles using PubMed, Cochrane Central, EMBASE, and Google Scholar. All studies reporting outcomes of TKA in patients with Parkinson disease, multiple sclerosis, poliomyelitis, Charcot joint, spina bifida, stroke, and cerebral palsy were included. RESULTS: In total 38 studies were included: 22 studies (461 patients) reported patient-reported outcome measures and 24 studies (510 patients) reported survivorship. All 38 studies reported complication rates. TKA resulted in an improvement in functional outcome in all series. Complication rate was higher in patients with neurologic conditions. Of studies reporting survivorship, mean follow-up ranged from 1 to 12 years with survivorship from 66% to 100%. All levels of implant constraint were reported without consensus. Limited rehabilitative data exist. CONCLUSION: TKA in patients with neurologic disorders improves symptoms and function but carries significant risk. This review helps surgeons preoperatively counsel their patients in an informed manner. Careful planning, perioperative care, and appropriate implant selection may mitigate risk of complication.

Are Virtual Fracture Clinics During the COVID-19 Pandemic a Potential Alternative for Delivering Fracture Care? A Systematic Review.

BACKGROUND: Virtual fracture clinics are an alternative to the traditional model of fracture care. Since their introduction in 2011, they have become increasingly used in the United Kingdom and Ireland. The coronavirus disease 2019 (COVID-19) health crisis has driven institutions to examine such innovative solutions to manage patient care. The current controversies include quantifying safety outcomes, such as potential delayed or missed injuries, inadequate treatment, and medicolegal claims. Questions also exist regarding the potential for cost reductions and efficiencies that may be achieved. Physical distancing has limited the number of face-to-face consultations, so this review was conducted to determine if virtual fracture clinics can provide an acceptable alternative in these challenging times. QUESTIONS/PURPOSES: The aim of this systematic review was to describe (1) adverse outcomes, (2) cost reductions, and (3) efficiencies associated with the virtual fracture clinic model. METHODS: A systematic review of the PubMed, MEDLINE, and Embase databases was conducted from database inception to March 2020. The keywords "virtual" or "telemedicine" or "telehealth" or "remote" or "electronic" AND "fracture" or "trauma" or "triage" AND "clinic" or "consultation" were entered, using the preferred reporting items for systematic reviews and meta-analyses. Inclusion criteria included adults and children treated for injuries by a virtual clinic model at the initial review. Eligible injuries included injuries deemed to not need surgical intervention, and those able to be treated remotely using defined protocols. Exclusion criteria consisted of patients reviewed by telemedicine using video links or in person at the initial review. Initially, 1065 articles were identified, with 665 excluded as they did not relate to virtual fracture clinics. In all, 400 articles were screened for eligibility, and 27 full-text reviews were conducted on 18 studies (30,512 virtual fracture clinic encounters). Three subdomains focusing on adverse outcomes, cost reductions, and efficiencies were recorded. The term adverse outcomes was used to describe any complications, further surgeries, re-referrals back to the clinic, or deviations from the protocols. Efficiency described the number of patients reviewed and discharged using the model, savings in clinic slots, reduced waiting times, or a reduction in consumption of resources such as radiographs. All studies were observational and the quality was assessed using Newcastle-Ottawa tool, which demonstrated a median score of 6 ± 1.8, indicating moderate quality. RESULTS: Six studies reported adverse outcomes in detail, with events ranging from inappropriate splinting, deviations from protocols, and one patient underwent an osteotomy for a malunion. Efficiency varied from direct discharge proportions of 18% in early studies to 100% once the virtual fracture clinic model was more established. Cost reductions compared with estimates derived from conventional fracture clinics varied from USD 53 to USD 297 and USD 39,125 to USD 305876 compared with traditional fracture clinic visits. CONCLUSIONS: Virtual fracture clinics may provide a means to treat patients remotely, using agreed-upon protocols. They have an important role in the current COVID-19 pandemic, due to the possibility to provide ongoing care in an otherwise challenging setting. More robust studies looking at this model of care will be needed to assess its long-term effects on patients, institutions, and health care systems. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Femoral offset found not to affect metal ion levels in metal-on-metal total hip arthroplasty.

BACKGROUND: Failure to restore femoral offset in metal on polyethylene total hip arthroplasty (THA) causes polyethylene wear and aseptic loosening. To our knowledge, no study to date has investigated the relationship between femoral offset and wear in metal-on-metal (MOM) THA. AIMS: In this study, we investigated the relationship between femoral offset and wear by measuring circulating metal ion levels in MOM THA. METHODS: In this retrospective study, we identified patients who had undergone MOM THA with the ASR XL system (DePuy International Ltd., Leeds, UK). Femoral offset was measured using anteroposterior radiographs, and circulating metal ion levels (cobalt and chromium) were recorded. RESULTS: In total, 95 patients were included (68 males and 27 females). The mean age at the time of surgery was 64.9. Mean time from surgery to blood sampling was 15.4 months. No statistically significant relationship was found between femoral offset and cobalt (p = 0.313) or chromium (p = 0.401) ions. CONCLUSION: It is known that failure to restore femoral offset during THA can lead to high rates of wear in metal-on-polyethylene articulations. In our study, no statistically significant relationship was found between femoral offset and serum cobalt or chromium ions. This study adds to the information available to surgeons regarding factors that increase wear in metal-on-metal total hip arthroplasty.

Consent documentation for elective orthopaedic surgery.

OBJECTIVES: Currently in Ireland, there is a lack of uniformity regarding the method in which the consent process is routinely documented. The purpose of this study was to evaluate the standard consent forms used in elective orthopaedic hospitals in Ireland. In addition, this paper explores the relevant guidelines from the UK and Ireland relating to consent documentation. METHODS: Standard consent forms used in the 24 public hospitals that perform elective orthopaedic surgery were analysed and compared, based on the inclusion or exclusion of 22 unique consent-related items or statements selected by the authors. In addition, each form was analysed for format, word count, and readability. RESULTS: Within 24 hospitals with elective orthopaedic surgery, there were 21 unique consent forms being used. There was a mean inclusion of 9.5 of the 22 unique items per form with a standard deviation of 5.1 (range 2-18), indicating a wide discrepancy. For each unique consent-related item in the analysis, the mean rate of inclusion was 43.4% (SD 26.7%). The mean Flesch Reading Ease Score was 43.3. The format varied from 1 to 4 pages, with a word count of 109 to 1041 (mean 414.7). CONCLUSION: The findings demonstrate a lack of uniformity of both format and content amongst the consent forms currently being used in elective orthopaedic hospitals in Ireland. This paper supports the use of a nationally standardised consent documentation method in order to improve the efficiency of the consent process and ensure greater protection against litigation.

Anaesthesia for total hip and knee replacement: A review of patient education materials available online.

Background: Patients frequently consult the internet for health information. Our aim was to perform an Internet-based readability and quality control study using recognised quality scoring systems to assess the patient information available online relating to anaesthesia for total hip and knee replacement surgery. Methods: Online patient information relating to anaesthesia for total hip and knee replacement was identified using Google, Bing and Yahoo with search terms 'hip replacement anaesthetic', 'knee replacement anaesthetic.' Readability was assessed using Flesch Reading Ease (FRE), Flesch-Kincaid grade level (FKGL) and Gunning Fog Index (GFI). Quality was assessed using DISCERN instrument, Health On the Net Foundation seal, and Information Standard mark. Results: 32 websites were analysed. 25% were HONcode certified, 15.6% had the Information Standard. Mean FRE was 55.2±12.8. Mean FKGL was 8.6±1.9. Six websites (18.8%) had the recommended 6 th-grade readability level. Mean of 10.4±2.6 years of formal education was required to read the websites. Websites with Information Standard were easier to read: FKGL (6.2 vs. 9, P < 0.001), GFI (8.8 vs. 10.7, P = 0.04), FRE score (64.2 vs. 9, P = 0.02). Mean DISCERN score was low: 40.3 ± 13. Conclusions: Overall, most websites were poor quality with reading levels too high for the target audience. Information Standard NHS quality mark was associated with improved readability, however along with HONcode were not found to have a statistically significant correlation with quality.  Based on this study, we would encourage healthcare professionals to be judicious in the websites they recommend to patients, and to consider both the readability and quality of the information provided.

Purple urine bag syndrome: a case report and review of the literature.

Purple urine bag syndrome (PUBS) is a rare and striking manifestation associated with urinary tract infection involving bright purple discoloration of the lining and tubing of a urinary catheter bag. We present the interesting case of a 90-year-old female patient who developed PUBS and include a review of the relevant literature to date. Uniquely, in this case, PUBS acts as an important clinical sign in supporting the diagnosis of urinary tract infection in a high-risk patient.

Laparoscopic resection of large gastric gastrointestinal stromal tumours.

INTRODUCTION: Gastrointestinal stromal tumours (GISTs) are a rare class of neoplasms that are seen most commonly in the stomach. Due to their malignant potential, surgical resection is the recommended method for management of these tumours. Many reports have described the ability to excise small and medium sized GISTs laparoscopically, but laparoscopic resection of GISTs greater than 5 cm is still a matter of debate. AIM: To investigate the feasibility and effectiveness of laparoscopic surgical techniques for management of large gastric GISTs greater than 4 cm and to detail characteristics of this type of tumour. MATERIAL AND METHODS: The study cohort consisted of 11 patients with suspected gastric GISTs who were treated from 2011 to April 2014 in a single institution. All patients underwent laparoscopic resection of a gastric GIST. RESULTS: Eleven patients underwent laparoscopic resection of a suspected gastric GIST between April 2011 and April 2014. The cohort consisted of 6 males and 5 females. Mean age was 67 years (range: 43-92 years). Sixty-four percent of these patients presented with symptomatic tumours. Four (36.4%) patients underwent laparoscopic transgastric resection (LTR), 3 (27.3%) laparoscopic sleeve gastrectomy (LSG), 3 (27.3%) laparoscopic wedge resection (LWR) and 1 (9%) laparoscopic distal gastrectomy (LDG). The mean operative time was 215 min. The mean tumour size was 6 cm (range: 4-9 cm). The mean tumour size for LTR was 5.5 cm (range: 4-6.3 cm), for LWR 5.3 cm (range: 4.5-7 cm), for LSG 6.5 cm (range: 4-9 cm) and for LDG 9 cm. We experienced only minor postoperative complications. CONCLUSIONS: Laparoscopic procedures can be successfully performed during management of large gastric GISTs, bigger than 4 cm, and should be considered for all non-metastatic cases. The appropriate approach can be determined by assessing the anatomical location of each tumour.

Atraumatic Fracture of a BIOLOX Delta Ceramic Femoral Head Articulating with a Polyethylene Liner: A Case Report.

CASE: We describe the case of a forty-one-year-old man who underwent total hip arthroplasty with a 32-mm BIOLOX delta ceramic head articulating with a polyethylene liner. The patient did not suffer any trauma postoperatively, and his only symptom was of a "clicking" noise from the operatively treated hip. At his six-week postoperative review, fracture of the femoral head was diagnosed. CONCLUSION: Fracture of a ceramic femoral head is a rare but catastrophic complication. This case report highlights the importance of vigilance on the part of the surgeon when reviewing patients after hip arthroplasty with ceramic-on-polyethylene bearing couples, even with limited symptoms associated with the hip and no reported trauma.