Impact of Different Operative Techniques for Patients With Adolescent Idiopathic Scoliosis on Frontal Curve Correction and Sagittal Balance

BACKGROUND

Surgical correction of adolescent idiopathic scoliosis from the posterior approach can be performed by the "all screws" technique; hybrid technique with screws and hooks; hybrid technique or with screws, hooks, and tapes; or selective fusion (SF) or nonselective fusion (NSF). The aim of the present investigation was to analyze the influence from different operative techniques on frontal curve correction and sagittal profile in patients with adolescent idiopathic scoliosis.

METHODS

We conducted a retrospective analysis on 55 consecutive patients with scoliosis who had been treated by posterior instrumented fusion. We collected demographic data and analyzed pre- and postoperative radiographs. Statistical analysis was performed using SPSS version 25. Because data showed normal distribution, t tests were performed.

RESULTS

Twenty-two patients were treated using the hybrid technique with screws and hooks; 25 were treated using the hybrid technique with screws, hooks, and tape; and 8 were treated using the all screws technique. An SF was performed in 32 patients and NSF in 23 patients. There was no significant difference with regard to curve correction of the main curve between the different techniques. Correction of the minor curve was significantly higher in NSF than in SF patients. In SF, there was a correction of the minor curve of 43.9%. Impact on sagittal balance showed no significant differences between NSF and SF.

CONCLUSION

The different operative techniques did not show a difference with regard to the correction of the main curve. NSF showed a significantly higher degree of correction of the minor curve than SF. However, we still found a correction of 43.9% of the noninstrumented minor curve in SF. Thus, SF and hybrid techniques do not lead to inferior radiographic outcome.

CLINICAL RELEVANCE

SF and hybrid techniques are safe and effective techniques that could be used as an alternative to NSF and all screw fixation in the operative treatment for scoliosis.

LEVEL OF EVIDENCE: 3

SalterHarris fractures in paediatric skiers and snowboarders

The incidence of paediatric fractures among winter sport athletes is not adequately studied. Our objective was to categorize fractures that occurred in paediatric skiers and snowboarders at a single ski resort. X-rays of 756 skiers/snowboarders aged 3-17 diagnosed with a fracture were categorized using the Salter-Harris (SH) classification. SH fractures were seen in 158 (21%) patients, with 123 (77%) being Type II. There were no significant differences between patients with a SH fracture and patients with a non-SH fracture for age, sex, snowboarding or skiing, mechanism of injury, terrain or the resort conditions on the day of injury. The most common mechanism of injury was falling onto snow while collisions resulted in more severe injuries. Compared to fractures without growth plate involvement, a higher proportion of SH fractures were seen in the humerus, radius, fibula and thumb; a lower proportion of SH fractures were observed at the tibia and clavicle.

An Increase in Vascular Stiffness Is Positively Associated With Mitochondrial Bioenergetics Impairment of Peripheral Blood Mononuclear Cells in the Older Adults

The cardio-ankle vascular index (CAVI) is a noninvasive parameter reflecting vascular stiffness. CAVI correlates with the burden of atherosclerosis and future cardiovascular events. Mitochondria of peripheral blood mononuclear cells (PBMCs) have been identified as a noninvasive source for assessing systemic mitochondrial bioenergetics. This study aimed to investigate the relationship between CAVI values and mitochondrial bioenergetics of PBMCs in the older adults.. This cross-sectional study enrolled participants from the Electricity Generating Authority of Thailand between 2017 and 2018. A total of 1 640 participants with an ankle-brachial index greater than 0.9 were included in this study. All participants were stratified into 3 groups based on their CAVI values as high (CAVI ≥ 9), moderate (9 > CAVI ≥ 8), and low (CAVI < 8), in which each group comprised 702, 507, and 431 participants, respectively. The extracellular flux analyzer was used to measure mitochondrial respiration of isolated PBMCs. The mean age of the participants was 67.9 years, and 69.6% of them were male. After adjusted with potential confounders including age, sex, smoking status, body mass index, diabetes, dyslipidemia, hypertension, and creatinine clearance, participants with high CAVI values were independently associated with impaired mitochondrial bioenergetics, including decreased basal respiration, maximal respiration, and spare respiratory capacity, as well as increased mitochondrial reactive oxygen species. This study demonstrated that CAVI measurement reflects the underlying impairment of cellular mitochondrial bioenergetics in PBMCs. Further longitudinal studies are necessary to establish both a causal relationship between CAVI measurement and underlying cellular dysfunction.

Flexible posterior vertebral tethering for the management of Scheuermann's kyphosis: correction by using growth modulation-clinical and radiographic outcomes of the first 10 patients with at least 3 years of follow-up

PURPOSE

The present prospective cohort study was intended to present the minimum 3 years' results of flexible posterior vertebral tethering (PVT) applied to 10 skeletally immature patients with SK to question, if it could be an alternative to fusion.

METHODS

Ten skeletally immature patients with radiographically confirmed SK, who had flexible (minimum 35%) kyphotic curves (T2-T12), were included. A decision to proceed with PVT was based on curve progression within the brace, and/or persistent pain, and/or unacceptable cosmetic concerns of the patient/caregivers, and/or non-compliance within the brace.

RESULTS

Patients had an average age of 13.1 (range 11-15) and an average follow-up duration of 47.6 months (range 36-60). Posterior vertebral tethering (PVT) was undertaken to all patients by utilizing Wiltse approach and placing monoaxial pedicle screws intermittently. At the final follow-up: mean pre-operative thoracic kyphosis and lumbar lordosis improved from 73.6°-45.7° to 34.7°-32.1°. Mean sagittal vertical axis, vertebral wedge angle and total SRS-22 scores improved significantly. A fulcrum lateral X-ray obtained at the latest follow-up, showed that the tethered levels remained mobile.

CONCLUSION

This study, for the first time in the literature, concluded, that as a result of growth modulation applied to skeletally immature patients with SK, flexible PVT was detected to yield gradual correction of the thoracic kyphosis by reverting the pathological vertebral wedging process, while keeping the mobility of the tethered segments in addition to successful clinical-functional results. The successful results of the present study answered the role of the PVT as a viable alternative to fusion in skeletally immature patients with SK.

LEVEL OF EVIDENCE

IV.

Rearfoot and Ankle Dislocations

Subtalar dislocations, ankle dislocations, and total talar dislocations are high-energy injuries. As such, there may be associated osseous or soft tissue injuries that can be diagnosed with advanced imaging such as computed tomography (CT) or MRI. With closed injuries, closed reduction may require sedation or general anesthesia, flexion of the knee to release the tension of the gastrocnemius-soleus complex, distraction is applied, the deformity is accentuated, then the deformity is corrected. Open injuries are usually associated with a higher level of energy and a higher rate of infection. It is important to thoroughly irrigate and debride open dislocations both before and after reduction.

Effect of lumbosacral transitional vertebra on developmental alterations of the hip: a quantitative investigation of the lumbo-pelvic-hip complex via whole-body computed tomography

Background

Lumbosacral transitional vertebra (LSTV) is a common spinal variant, with the reported prevalence varying from 8.1% to 36%. LSTV has been shown to alter the lumbo-pelvic parameters and reduce the benefits of total hip arthroplasty, but the specific effects of LSTV on hip development remain unclear. The aim of this study was thus to investigate the impact of LSTV on developmental alterations of the hip.

Methods

A total of 310 individuals were categorized into three groups according to whole-body computed tomography (CT) imaging: a group with sacralization of 23 presacral vertebrae (PSV) (n=102), a group with lumbarization of 25 PSV (n=108), and a normal control group with 24 PSV (n=100). Quantitative parameters of the lumbo-pelvic-hip complex (LPHC) including lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), axial and sagittal acetabular anteversion angle (AAA), center-edge (CE) angle, Sharp angle, and femoral neck-shaft angle (FNSA) were measured and analyzed. Statistical analyses were used to compare the differences of these quantitative parameters among the three groups and to assess the relationship between hip and lumbar-pelvic parameters.

Results

Significant differences between each pair of three groups and the LSTV subgroups were only found in the sagittal AAA (left side: P=0.008; right side: P<0.001), with no differences found for the other parameters. Compared to the normal group (24 PSV), both the 23 PSV and 25 PSV groups exhibited increased values in the sagittal AAA, especially in the right side of the 23 PSV group. Only the sagittal AAA showed low-to-moderate positive correlations with pelvic parameters of PI (r=0.195-0.429; P=0.001-0.08) and PT (r=0.239-0.605; P=0.001-0.03).

Conclusions

Variations of LSTV are correlated with the hip anatomical development via LPHC transmission and may potentially reduce the sagittal acetabular coverage, particularly in the 23 PSV subtype on the right side.

The effect of distal locking mode on postoperative mechanical complications in intertrochanteric fractures: a retrospective cohort study of five hundred and seven patients

PURPOSE

The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II.

METHODS

Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings.

RESULT

Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215-9.041; and OR = 3.652, 95% CI: 1.451-9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses.

CONCLUSION

Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture.

Early Management for Fracture-Related Infection: A Literature Review

Fracture-related infections (FRIs), as shown in the literature, represent one of the main complications of trauma surgery. They are a consequence of an implant-related "biofilm" formation and are a challenge for surgeons, microbiologists, and infectious disease specialists. For a correct diagnosis, careful clinical evaluation, to look for signs/symptoms attributable to an infectious condition, and instrumental examinations, to highlight the site of infection, its extent, and its severity, are both essential. Unfortunately, due to the lack of data in the literature, there is no consensus about guidelines on the diagnosis and treatment of FRIs. The purpose of this study is to present an up-to-date concept evaluation of the diagnostic procedures and treatment options available in the management of fracture-related infections.

Open Reduction and Internal Fixation with Plate and Screw versus Triplanar External Fixation in the Surgical Treatment of Calcaneal Fractures: A Retrospective Cohort Study

Background: The treatment of displaced intra-articular calcaneal fractures (DIACF) is debated. This study compares open reduction and internal fixation (ORIF) with minimally invasive osteosynthesis (MIOS). Methods: We conducted a retrospective study on 70 patients with DIACF treated between January 2018 and September 2022, divided into ORIF (n = 50) and MIOS (n = 20) groups. Functional outcomes were assessed using the Maryland Foot Score (MFS) and the Creighton-Nebraska Health Foundation Assessment Scale (CNHFAS). Radiographic outcomes, complication rates, and reintervention rates were evaluated. A chi-square analysis examined the correlation between Sanders classification and treatment choice. Results: The chi-square analysis indicated no significant correlation between the complexity of the fracture and the type of treatment chosen (χ2 = 0.175, p = 0.916). Additionally, the Cochran-Armitage test for trend showed no significant trend in the choice of treatment based on fracture complexity (statistic = 0.048, p = 0.826). A Kaplan-Meier analysis showed a longer time to reintervention for MIOS (p = 0.029). Complication rates were similar, with specific complications varying between groups. Quality-of-life outcomes were comparable. Conclusions: ORIF is preferable for high-demand patients due to better anatomical outcomes, while MIOS suits high-risk patients by reducing reinterventions and complications. Further randomized trials are needed to confirm these findings.

Deformity correction from the convexity of the curve in neuromuscular scoliosis

Background

"Convex Pedicle Screw Technique" reduces the theoretical risk of neurovascular injury. Our aim is to evaluate the efficacy of this technique in patients with neuromuscular scoliosis (NMS).

Methods

Retrospective study of 12 patients who underwent a Convex Pedicle Screw Technique and were diagnosed with NMS. Patients who had undergone previous spinal surgery were excluded. The minimum follow-up required was 24 months. Demographic data, intraoperative data, neurovascular complications and neurophysiological events requiring implant repositioning, as well as pre- and postoperative radiological variables were collected.

Results

Twelve patients diagnosed with NMS underwent surgery. The median operative time was 217 minutes. Mean blood loss was 3.8±1.1 g/dL hemoglobin (Hb). The median postoperative stay was 8.8±4 days. A reduction of the Cobb angle in primary curve of 49.1% (from 52.8°±18° to 26.5°±12.6°; P<0.001) and in secondary curve of 25.2% (from 27.8°±18.9° to 18.3°±13.3°; P=0.10) was achieved. Coronal balance improved by 69.4% (7.5±46.2 vs. 2.3±20.9 mm; P=0.72) and sagittal balance by 75% (from -14.1±71.8 vs. -3.5±48.6 mm; P=0.50). There were no neurovascular complications. There were no intraoperative neurophysiological events requiring implant repositioning, nor during reduction maneuvers. No infections were reported.

Conclusions

The correction of the deformity from convexity in NMS achieves similar results to other techniques, and a very low complication rate.

Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion

Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.

Three predictive scores compared in a retrospective multicenter study of nonunion tibial shaft fracture

BACKGROUND

Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging.

AIM

To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion.

METHODS

We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation.

RESULTS

Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing.

CONCLUSION

LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.

Methods to accelerate fracture healing - a narrative review from a clinical perspective

Bone regeneration is a complex pathophysiological process determined by molecular, cellular, and biomechanical factors, including immune cells and growth factors. Fracture healing usually takes several weeks to months, during which patients are frequently immobilized and unable to work. As immobilization is associated with negative health and socioeconomic effects, it would be desirable if fracture healing could be accelerated and the healing time shortened. However, interventions for this purpose are not yet part of current clinical treatment guidelines, and there has never been a comprehensive review specifically on this topic. Therefore, this narrative review provides an overview of the available clinical evidence on methods that accelerate fracture healing, with a focus on clinical applicability in healthy patients without bone disease. The most promising methods identified are the application of axial micromovement, electromagnetic stimulation with electromagnetic fields and direct electric currents, as well as the administration of growth factors and parathyroid hormone. Some interventions have been shown to reduce the healing time by up to 20 to 30%, potentially equivalent to several weeks. As a combination of methods could decrease the healing time even further than one method alone, especially if their mechanisms of action differ, clinical studies in human patients are needed to assess the individual and combined effects on healing progress. Studies are also necessary to determine the ideal settings for the interventions, i.e., optimal frequencies, intensities, and exposure times throughout the separate healing phases. More clinical research is also desirable to create an evidence base for clinical guidelines. To make it easier to conduct these investigations, the development of new methods that allow better quantification of fracture-healing progress and speed in human patients is needed.

On-demand release of a selective MMP-13 blocker from an enzyme-responsive injectable hydrogel protects cartilage from degenerative progression in osteoarthritis

In osteoarthritis (OA), the degradation of cartilage is primarily driven by matrix metalloprotease-13 (MMP-13). Hence, the inhibition of MMP-13 has emerged as an attractive target for OA treatment. Among the various approaches that are being explored for MMP-13 regulation, blocking of the enzyme with specific binding molecules appears to be a more promising strategy for preventing cartilage degeneration. To enhance effectiveness and ensure patient compliance, it is preferable for the binding molecule to exhibit sustained activity when administered directly into the joint. Herein, we present an enzyme-responsive hydrogel that was designed to exhibit on-demand, the sustained release of BI-4394, a potent and highly selective MMP-13 blocker. The stable and compatible hydrogel was prepared using triglycerol monostearate. The efficacy of the hydrogel to prevent cartilage damage was assessed in a rat model of OA induced by anterior cruciate ligament transection (ACLT). The results revealed that in comparison to the rats administrated weekly with intra-articular BI-4394, the hydrogel implanted rats had reduced levels of inflammation and bone erosion. In comparison to untreated control, the cartilage in animals administered with BI-4394/hydrogel exhibited significant levels of collagen-2 and aggrecan along with reduced MMP-13. Overall, this study confirmed the potential of BI-4394 delivery using an enzyme-responsive hydrogel as a promising treatment option to treat the early stages of OA by preventing further cartilage degradation.

A Secondary Analysis of Gender Respiratory Features for Ultrasonography Bilateral Diaphragm Thickness, Respiratory Pressures, and Pulmonary Function in Low Back Pain

The aim of the present study was to determine the gender respiratory differences of bilateral diaphragm thickness, respiratory pressures, and pulmonary function in patients with low back pain (LBP). A sample of 90 participants with nonspecific LBP was recruited and matched paired by sex (45 women and 45 men). Respiratory outcomes included bilateral diaphragm thickness by ultrasonography, respiratory muscle strength by maximum inspiratory (MIP) and expiratory (MEP) pressures, and pulmonary function by forced expiratory volume during 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC spirometry parameters. The comparison of respiratory outcomes presented significant differences (p < 0.001), with a large effect size (d = 1.26-1.58) showing means differences (95% CI) for MIP of -32.26 (-42.99, -21.53) cm H2O, MEP of -50.66 (-64.08, -37.25) cm H2O, FEV1 of -0.92 (-1.18, -0.65) L, and FVC of -1.00 (-1.32, -0.69) L, with lower values for females versus males. Gender-based respiratory differences were presented for maximum respiratory pressures and pulmonary function in patients with nonspecific LBP. Women presented greater inspiratory and expiratory muscle weakness as well as worse lung function, although these differences were not linked to diaphragm thickness during normal breathing.

Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Methods

A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value.

Results

A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm.

Conclusion

Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.

Mid-Term Outcomes of a Short Modular Neck-Preserving Cementless Hip Stem: A Retrospective Study With a 6-Year Minimum Follow-Up

BACKGROUND

The neck-preserving cementless short stem represents a valid therapeutic option for total hip replacement in high-functional-demand patients, but few studies are available about the use of modularity in the last-generation short stem. The aim of the study was to evaluate the mid-term survival of a specific implant design that combines partial collum short hip stem with neck modularity; assessing the functional status was the second endpoint.

METHODS

A retrospective single-center cohort study was conducted on 75 patients aged 35 to 80 years, with a minimum 6-year follow-up. Patients with neurological/rheumatic pathologies and previous hip surgeries were excluded. All the patients underwent total hip replacement with a short modular neck-preserving cementless hip stem. Clinical outcomes, complications, revisions, and the Western Ontario and McMaster Universities Osteoarthritis Index, Harris hip score, and Short Form 12-Item Health Survey (SF-12) questionnaires were evaluated. The results were compared with healthy population's data extracted from the literature, stratified by age.

RESULTS

The Kaplan-Meier analysis revealed a 10-year implant survival rate of 96.7%, coupled with a revision rate of 1.3%. Results showed a Harris hip score and physical SF-12 significantly lower and a mental SF-12 higher when compared to healthy population. No statistically significant differences emerged when comparing groups based on neck modularity.

CONCLUSIONS

The short modular neck-preserving cementless hip stem emerged as a reasonable choice for patients with elevated functional demands, ensuring good clinical outcomes while preserving bone integrity. The use of a modular neck in short stems didn't show any mechanical problems in the mid-term.

Postoperative complications after displaced intra-articular calcaneal fracture operations

BACKGROUND

The objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group.

METHODS

A total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders's classification and improvement of Böhler's angle were analyzed.

RESULTS

Early complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler's angle.

CONCLUSION

Complication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF.

LEVEL OF EVIDENCE

IV retrospective cohort study at a single institution.

Syndesmosis Injury Contributes a Large Negative Effect on Clinical Outcomes: A Systematic Review

INTRODUCTION

The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. This systematic review aimed to quantify the impact of syndesmosis injury.

METHODS

Published clinical outcomes data were used to compute an effect size reflecting the impact of syndesmosis injury. This was done within the clinical contexts of isolated syndesmosis injury and syndesmosis injury with concomitant ankle fracture. Clinical outcomes data included Olerud-Molander (OM) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale for pain, and days missed from sport competition. Parametric data were compared with Student t tests. Effect size was computed using Cohen's d.

RESULTS

In ankle fracture patients, syndesmosis injury demonstrated a large effect size for OM (d = 0.96) and AOFAS (d = 0.83) scores. In athletic populations without concomitant ankle fracture, syndesmosis injury demonstrated a large effect size on days missed from competition (d = 2.32).

DISCUSSION

These findings confirm the magnitude of the negative impact of syndesmosis injury in athletic populations with isolated injury and in ankle fracture patients. In ankle fracture patients, this large negative effect remains despite surgery. Thus, syndesmosis repair may not fully mitigate the impact of the injury.

LEVELS OF EVIDENCE

Level III: Systematic review.

Hidden blood loss and bleeding characteristics in children with congenital scoliosis undergoing spinal osteotomies

PURPOSE

Spinal osteotomies are often essential in the treatment of congenital scoliosis. Risk factors for bleeding in these patients needing extracavitatory approaches, especially hidden blood loss, are sparsely investigated. We aimed to investigate the bleeding characteristics and hidden blood loss in paediatric patients undergoing spinal osteotomies for congenital scoliosis.

METHODS

A retrospective analysis identified all patients with congenital scoliosis were retrospectively identified from the prospectively collected spine register from 2010 to 2022. Operative technique, perioperative laboratory results and imaging studies were extracted. The primary outcome was total blood loss including intraoperative, drain output and hidden blood loss.

RESULTS

Fifty-seven children (32 boys) with a mean age of 8.3 years underwent spinal osteotomy for congenital scoliosis. Posterolateral hemivertebrectomy was sufficient in 34 (59%) patients, while vertebral column resection (VCR) was required in 23 patients. Total bleeding averaged 792 (523) ml accounting for 42% of the estimated blood volume. Hidden blood loss accounted for 40% of total bleeding and 21% of estimated blood volume with a mean of 317 (256) ml. VCR was associated with greater intraoperative and total bleeding than hemivertebrectomies (p = 0.001 and 0.007, respectively). After adjusting for patient weight and fusion levels, hidden blood loss was larger in hemivertebrectomies (4.18 vs. 1.77 ml/kg/fused level, p = 0.049). In multivariable analysis, intraoperative blood loss was inversely correlated with preoperative erythrocyte levels. Younger age was associated with significantly greater drain, hidden and total blood loss.

CONCLUSION

Hidden blood loss constitutes a significant portion (40%) of total bleeding in congenital scoliosis surgery. Younger age is a risk factor for bleeding and the hidden blood loss should be taken into consideration in their perioperative management.

A review on manufacturing processes of cobalt-chromium alloy implants and its impact on corrosion resistance and biocompatibility

Cobalt-Chromium (CoCr) alloys are currently used for various cardiovascular, orthopedic, fracture fixation, and dental implants. A variety of processes such as casting, forging, wrought processing, hot isostatic pressing, metal injection molding, milling, selective laser melting, and electron beam melting are used in the manufacture of CoCr alloy implants. The microstructure and precipitates (carbides, nitrides, carbonitrides, and intermetallic compounds) formed within the alloy are primarily determined by the type of manufacturing process employed. Although the effects of microstructure and precipitates on the physical and mechanical properties of CoCr alloys are well reviewed and documented in the literature, the effects on corrosion resistance and biocompatibility are not comprehensively reviewed. This article reviews the various processes used to manufacture CoCr alloy implants and discusses the effects of manufacturing processes on corrosion resistance and biocompatibility. This review concludes that the microstructure and precipitates formed in the alloy are unique to the manufacturing process employed and have a significant impact on the corrosion resistance and biocompatibility of CoCr alloys. Additionally, a historical and scientific overview of corrosion and biocompatibility for metallic implants is included in this review. Specifically, the failure of CoCr alloys when used in metal-on-metal bearing surfaces of total hip replacements is highlighted. It is recommended that the type of implant/application (orthopedic, dental, cardiovascular, etc.) should be the first and foremost factor to be considered when selecting biomaterials for medical device development.

Exploring Factors Associated With Resilience and Physical Activity in Older Men and Women Post-Hip Fracture

This study aimed to test a model of factors associated with resilience and physical activity post-hip fracture and compare model fit between men and women. We used data from the seventh Baltimore Hip Study that included 339 participants. Model testing indicated that health status (men: β = .237, p = .002; women: β = .265, p = <.001), depression (men: β = -.245, p = .001; women: β = -.241, p = <.001), and optimism (men: β = .320, p = <.001; women: β = .282, p = <.001) were associated with resilience in men and women, but resilience was only associated with physical activity in men (β = .203, p = .038) and not in women. Social interaction was related to physical activity only among women (β = .206, p = .044). This study provides support for the relationship between resilience and physical activity at least among men.

Surgical Management of Tumoral Calcinosis of the Hand: A Case Report

Primary tumoral calcinosis is a rare and benign condition characterized by calcium salt deposition in periarticular soft tissues. It typically presents as a firm, rubbery mass that arises around large joints. While an estimated 250 cases have been described since its discovery, very few cases have been identified in the hand. We present a case of multiple calcified masses in the hand, one of which required meticulous dissection from a digital neurovascular bundle, and our technique for surgical excision. We present this case to lower the threshold for clinical suspicion of tumoral calcinosis for patients who present with a soft tissue mass in the hand. Furthermore, we recommend prompt surgical excision due to low success rates of alternative treatment options and to prevent potential neurovasculature or tendon injury.

Comparison of clinical outcomes and repair integrity after arthroscopic versus mini-open rotator cuff repair: An observational study

This study aimed to evaluate the differences between mini-open (MO) and arthroscopic (ART) repair procedures for rotator cuff tendon tears in terms of clinical and radiological outcomes. This retrospective study included 59 patients, and data were collected prospectively. Patients with full-thickness rotator cuff tears were randomized to undergo MO or ART repair at 2 centers by 2 surgeons between January 2012 and December 2017. Data were collected 3 weeks before surgery and 6 and 12 months after surgery. Physical function was assessed using the American Shoulder and Elbow Surgeons index, VAS, and Constant scoring system. Radiological outcomes were assessed using the Sugaya classification, adapted for ultrasound. Changes between baseline and follow-up were compared between the 2 groups. Fifty-nine patients who underwent ART or MO rotator cuff repair were included in this study. The 2 groups had similar demographic characteristics and preoperative baseline parameters. Both the MO and ART groups showed statistically significant improvement in outcome parameters (P ≤ .0001); however, cuff repair integrity was significantly better in the ART group (P = .023). All other improvements in the patient-derived parameters were equivalent. None of the patients in either group required revision surgery. According to the results of our retrospective study, MO and ART rotator cuff repair are effective and viable options for surgeons to repair rotator cuff tears. There were no differences in objective and subjective outcomes between the full ART and MO techniques for rotator cuff tears. Surgeons should choose a technique with which they are more familiar.

Risk of Periprosthetic Joint Infection after Intra-Articular Injection: Any Difference among Shoulder, Knee and Hip?

Osteoarthritis is a degenerative joint disease caused by the wear and tear of joint cartilage. The definitive and resolving treatment is prosthetic replacement of the articular surface, the demand of which is on the rise for patients with mild to moderate severity. However, a conservative strategy may be considered that aims to reduce and contain pain symptoms by postponing surgical treatment in the case of worsening that can no longer be otherwise controlled. Intra-articular infiltrations, like other therapeutic strategies, are not without complications, and among these the most feared is joint infection, especially in anticipation of future prosthetic replacement. Is important to avoid periprosthetic joint infections because they represent one of the third most common reasons for revision surgery. Using cases found in the literature, the aim of this article is to determine if there is a real correlation between the type of injections, the number of doses injected and the time between infiltrations and the surgical procedure.

Integrated Network Pharmacology and Experimental Validation Approach to Investigate the Mechanisms of Radix Rehmanniae Praeparata - Angelica Sinensis - Radix Achyranthis Bidentatae in Treating Knee Osteoarthritis

Background

Knee osteoarthritis (KOA) is a persistent degenerative condition characterized by the deterioration of cartilage. The Chinese herbal formula Radix Rehmanniae Praeparata- Angelica Sinensis-Radix Achyranthis Bidentatae (RAR) has often been used in effective prescriptions for KOA as the main functional drug, but its underlying mechanism remains unclear. Therefore, network pharmacology and verification experiments were employed to investigate the impact and mode of action of RAR in the treatment of KOA.

Methods

The destabilization of the medial meniscus model (DMM) was utilized to assess the anti-KOA effect of RAR by using gait analysis, micro-computed tomography (Micro-CT), and histology. Primary chondrocytes were extracted from the rib cartilage of a newborn mouse. The protective effects of RAR on OA cells were evaluated using a CCK-8 assay. The antioxidative effect of RAR was determined by measuring reactive oxygen species (ROS), superoxide dismutase (SOD), and glutathione (GSH) production. Furthermore, network pharmacology and molecular docking were utilized to propose possible RAR targets for KOA, which were further verified through experiments.

Results

In vivo, RAR significantly ameliorated DMM-induced KOA characteristics, such as subchondral bone sclerosis, cartilage deterioration, gait abnormalities, and the degree of knee swelling. In vitro, RAR stimulated chondrocyte proliferation and the expression of Col2a1, Comp, and Acan. Moreover, RAR treatment significantly reduced ROS accumulation in an OA cell model induced by IL-1β and increased the activity of antioxidant enzymes (SOD and GSH). Network pharmacology analysis combined with molecular docking showed that Mapk1 might be a key therapeutic target. Subsequent research showed that RAR could downregulate Mapk1 mRNA levels in IL-1β-induced chondrocytes and DMM-induced rats.

Conclusion

RAR inhibited extracellular matrix (ECM) degradation and oxidative stress response via the MAPK signaling pathway in KOA, and Mapk1 may be a core target.

Accuracy of cup placement compared with preoperative surgeon targets in primary total hip arthroplasty using standard instrumentation and techniques: a global, multicenter study

BACKGROUND

Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures is in question. Several studies have raised concerns about the benefits of using the Lewinnek safe zone as a predictor of success. In this study we elected to use prospective surgeon targets as the basis for comparison to see how successful surgeons are positioning their cup using standard instruments and techniques.

METHODS

A prospective, global, multicenter study was conducted. Cup positioning success was defined as a composite endpoint. Both cup inclination and version needed to be within 10° of the surgeon target to be considered a success. Radiographic analysis was conducted by a third-party reviewer.

RESULTS

In 170 subjects, inclination, target versus actual, was 44.8° [standard deviation (SD 0.9°)] and 43.1° (SD 7.6°), respectively (p = 0.0029). Inclination was considered successful in 84.1% of cases. Mean version, target versus actual, was 19.4° (SD 3.9°) and 27.2° (SD 5.6°), respectively (p < 0.0001). Version was considered successful in 63.4% of cases, and combined position (inclination and version) was considered successful in 53.1%.

CONCLUSION

This study shows that with traditional methods of placing the cup intraoperatively, surgeons are only accurate 53.1% of the time compared with a predicted preoperative plan. This study suggests that the inconsistency in cup positioning based on the surgeon's planned target is potentially another important variable to consider while using a mechanical guide or in freehand techniques for cup placement in THA.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov, NCT03189303.

An examination from 1990 to 2019: investigating the burden of knee dislocation on a global scale

Background

The literature on the disease burden of knee dislocation is lacking. The aim of the study is to systematically assess the global burden, trends, causes, and influencing factors of knee dislocation.

Methods

The incidence and years lived with disability (YLDs) of knee dislocation were assessed globally, as well as at the regional and national levels from 1990 to 2019. Subsequent analyses focused on the age and gender distribution related to knee dislocation. An investigation into the main causes of knee dislocation followed. Finally, the Pearson correlation between age-standardized rates and social-demographic index (SDI) was calculated.

Results

Although the age-standardized incidence and YLDs rate of knee dislocation decreased over the past 30 years, the incidence and YLDs number increased. The disease burden remained higher in males compared to females. Males and females showed different patterns of incidence rates in each age group, but their YLDs rates were similar. Over the past 30 years, the disease burden of knee dislocation increased in the older population while declining in the younger population. Falls had consistently emerged as the most important cause for both incidence and YLD rates. Additionally, a positive correlation between SDI and the disease burden of knee dislocation was found.

Conclusion

The disease burden of knee dislocation remains heavy. It is essential to recognize the evolving epidemiology of knee dislocation. Utilizing data-driven assessments can assist in formulating public health policies and strategies to improve overall well-being.

Fracture of femoral neck in modular total hip arthroplasty: a systematic review of the literature

BACKGROUND

Modular femoral stems have the advantage of anatomic hip reconstruction by restoring the femoral offset thus minimising the bearing surface wear, implant loosening and dislocation.

AIM

This study aims to investigate the existing literature on modular neck fractures, to identify predisposing factors and guide the decision-making process in the management of these difficult cases.

METHODS

A systematic literature review was conducted until July 2022. PRISMA guidelines were followed, eligibility criteria were set, and methodology assessment of included studies was conducted based on MINORS criteria, size and primary outcome. Data were extracted and analysed thoroughly.

RESULTS

5657 studies were initially screened; the full texts of 124 records were assessed and finally, 32 reports were included. There were 7 clinical studies and 25 case reports. A total of 4825 patients (5204 hips) with a mean age 62.38 years and a mean BMI 29.06 kg/m2 were analysed in the 7 clinical studies. The reported overall weighted revision rate was 0.86%, while the weighted mean modular neck fracture rate was 0.26%. The usual history was sudden experience of hip pain and instability. The average time interval to neck fracture was 4.57 (range 3-4.7) years and a long modular neck was identified in 91.17% of them. Data from case reports showed a mean age and average BMI of 55.85 and 31.63 kg/m2. 82.35% of the patients were male. Necks were fractured after an average time interval of 64.5 ± 8.8 months.

CONCLUSIONS

The incidence of modular neck fracture is significant. The profile of a male, obese patient with a long modular neck increased risk of neck fracture. Microstructural investigation of the retrieved implants demonstrated a higher incidence of fracture line in the base of the neck junction and at its anterolateral distal part. Surgeons should be aware of this complication while using or revising such protheses.

Intra- and inter-observer reliability of Dias-Tachdjian classification in pediatric ankle fractures: do clinical experience and expertise matter?

The Dias-Tachdjian classification is the most commonly used system for the classification of pediatric ankle fractures, but its inter- and intra-observer reliability has not been studied in detail. Also, the impact of the clinician's experience and expertise on the reliability of this system is unknown. This study aimed: (1) to determine the intra- and inter-observer reliability of the Dias-Tachdjian classification and (2) to investigate the effect of the clinician's experience and expertise on the reliability of this system. Anteroposterior and lateral ankle radiographs of 56 children (34 male, 22 female) with ankle fractures, aged between 3 and 14 years, with open growth cartilages, were retrospectively identified and included in the study. Each patient radiograph was examined by 10 observers from two different specialties with different levels of clinical experience (two orthopedic surgeons with interest in pediatric orthopedics, three orthopedic surgeons with no interest in pediatric orthopedics, three orthopedic residents, and two radiology specialists) from two different specialties (orthopedics and radiology). All observers were then asked to classify pediatric ankle fractures at 6-week intervals per the Dias-Tachdjian classification system. Overall, intra-observer reliability as substantial to very good (κ = 0.77-0.95, P < 0.01), but inter-observer reliability as fair for both assessments (κ = 0.21, P < 0.01 and κ = 0.20, P < 0.01 for the first and second occasions, respectively). Inter-observer reliability among pediatric orthopedic surgeons as very good (κ = 0.90, 95% CI = 0.86-0.94, P < 0.01 and κ = 0.82, 95% CI = 0.71-0.93, P < 0.01 for the first and second occasions, respectively). Orthopedic surgeons with no special interest in pediatric orthopedics demonstrated substantial agreement in the first occasion (κ = 0.63, 95% CI = 0.53-0.72, P < 0.01) but moderate in the second one. Orthopedic residents exhibited moderate levels of agreement in each assessment period (κ = 0.58, 95% CI = 0.47-0.68, P < 0.01 and κ = 0.44, 95% CI = 0.37-0.51, P < 0.01 for the first and second occasion, respectively). Considering that the specialists dealing with pediatric orthopedics show very good consistency for Dias-Tachdjian classification, both within and between observers, consistency in the identification of the ankle fracture models increases as the interest in the field of pediatric orthopedics intensifies.

Sex-related differences in periprosthetic joint infection research

Introduction: Periprosthetic joint infections (PJIs) have emerged as a focal point in the realm of orthopedics, garnering widespread attention owing to the escalating incidence rates and the profound impact they impose on patients undergoing total joint arthroplasties (TJAs). Year after year, there has been a growing trend in the analysis of multiple risk factors, complication rates, and surgical treatments in the field. This study aims to illuminate the status of the sex-related differences in periprosthetic joint infections and advance research in this field. Methods: A systematic review was carried out following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The final reference list comprised longitudinal studies (both retrospective and prospective) and randomized controlled trials. A sex-based analysis was conducted to assess differences between males and females. Results: A total of 312 studies were initially identified through online database searches and reference investigations. Nine studies were subsequently included in the review. Eight out of nine studies examined the risk of developing PJI after total joint replacement. Notably, only half of these studies demonstrated a statistically significant value, with a p  value  < 0.05 , indicating a higher risk of infectious complications in males compared to females. Conclusion: According to the current literature, there appears to be a propensity for males to develop periprosthetic joint infection after total joint arthroplasty at a higher rate than the female population. Enhancing sex-related analysis in this field is imperative for gathering more robust evidence and insights.

Investigating and Practicing Orthopedics at the Intersection of Sex and Gender: Understanding the Physiological Basis, Pathology, and Treatment Response of Orthopedic Conditions by Adopting a Gender Lens: A Narrative Overview

In the biomedical field, the differentiation between sex and gender is crucial for enhancing the understanding of human health and personalizing medical treatments, particularly within the domain of orthopedics. This distinction, often overlooked or misunderstood, is vital for dissecting and treating musculoskeletal conditions effectively. This review delves into the sex- and gender-specific physiology of bones, cartilage, ligaments, and tendons, highlighting how hormonal differences impact the musculoskeletal system's structure and function, and exploring the physiopathology of orthopedic conditions from an epidemiological, molecular, and clinical perspective, shedding light on the discrepancies in disease manifestation across sexes. Examples such as the higher rates of deformities (adolescent idiopathic and adult degenerative scoliosis and hallux valgus) in females and osteoporosis in postmenopausal women illustrate the critical role of sex and gender in orthopedic health. Additionally, the review addresses the morbidity-mortality paradox, where women, despite appearing less healthy on frailty indexes, show lower mortality rates, highlighting the complex interplay between biological and social determinants of health. Injuries and chronic orthopedic conditions such osteoarthritis exhibit gender- and sex-specific prevalence and progression patterns, necessitating a nuanced approach to treatment that considers these differences to optimize outcomes. Moreover, the review underscores the importance of recognizing the unique needs of sexual minority and gender-diverse individuals in orthopedic care, emphasizing the impact of gender-affirming hormone therapy on aspects like bone health and perioperative risks. To foster advancements in sex- and gender-specific orthopedics, we advocate for the strategic disaggregation of data by sex and gender and the inclusion of "Sexual Orientation and Gender Identity" (SOGI) data in research and clinical practice. Such measures can enrich clinical insights, ensure tailored patient care, and promote inclusivity within orthopedic treatments, ultimately enhancing the precision and effectiveness of care for diverse patient populations. Integrating sex and gender considerations into orthopedic research and practice is paramount for addressing the complex and varied needs of patients. By embracing this comprehensive approach, orthopedic medicine can move towards more personalized, effective, and inclusive treatment strategies, thereby improving patient outcomes and advancing the field.

Health Care Utilization for Common Shoulder Disorders: Analysis of the 2010-2019 National Patient Sample Data from the Health Insurance Review and Assessment Service in Korea

Background and Objective: The aim of this study was to analyze trends in surgical and non-surgical service utilization for common shoulder disorders in Korea from 2010 to 2019. Methods and Materials: This retrospective, cross-sectional, descriptive study utilized National Patient Sample data from the Health Insurance and Review Assessment Service (HIRA) of Korea. These data constitute a 2% sample out of the entire Korean population and include data for a variety of parameters instrumental for health care research. Patients with at least one medical service use for rotator cuff syndrome or tear, impingement syndrome, or adhesive capsulitis between January 2010 and December 2019 were included. Trends in healthcare utilization by disorder type, patient demographics, seasonal service use, and treatment details were examined. Results: There was an upward trend in the total number of patients and costs for shoulder disorders, from 35,798 patients and USD 5,485,196 in 2010 to 42,558 and USD 11,522,543 in 2019, respectively. The number of patients aged ≥60 and hospital visits increased. March had the highest number of claims. Physical therapy was the most common non-surgical procedure, while nerve block claims more than doubled. Opioid prescription rates also tripled. Surgical treatments were dominated by shoulder rotator cuff repair and acromioplasty. Conclusions: There was a significant increase in healthcare utilization for shoulder disorders, marked by rising costs and patient numbers. The use of nerve blocks and opioids notably increased. These data are valuable for clinicians, researchers, and policymakers.

Ultrasound-Guided Hip Injections with High Density Hyaluronic Acid: Outcome at One Year Follow Up

Background: The ultrasound-guided viscosupplementation of the hip joint with hyaluronic acid (HA) is considered a standard procedure among the conservative treatments for hip arthritis. The aim of this study was to evaluate the clinical benefit and the incidence of adverse events of the technique in an observational study at one year follow up. Methods: We evaluated a consecutive series of 85 patients with a diagnosis of symptomatic arthritis who underwent intra-articular ultrasound-guided hyaluronic acid injections. The scales used for evaluation were modified Harris Hip Score (mHHS), WOMAC (Western Ontario and McMaster University), and Hip Outcome Score (HOS) with subscale Sport (HOSs), for pain the Visual Analogic Scale (VAS). The patients were classified according to Tonnis' radiological classification of arthritis (range 0-3): 20 patients (grade 0), 32 (grade 1), 18 (grade 2), 15 (grade 3). Results: At last follow up, all the scales increased: mHHS from 59.35 to 82.1, HOS from 69.45 to 78.53, HOss from 47.4 to 58.11, VAS from 6.09 to 3.97, WOMAC from 33.2 to 31.5 (p < 0.05 for all the parameters); the results were elaborated with GraphPad Prism v5.0 (Prism Software La Jolla, CA, USA) using Wilcoxon's test. A total of 13 patients out of 85 needed arthroplasty, all classified as Tonnis grade 3. No serious adverse events were noted due to the procedure. Conclusions: Based on our findings, indication for the use of hyaluronic acid is limited to patients with mild to moderate arthritis. Patients in advanced arthritis refusing replacement surgery and asking for this treatment should be informed about the poor results of the technique even in the short term.

Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature

Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient's psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews.

Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study

BACKGROUND

Hemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis.

METHODS

Consecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE).

RESULTS

38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up.

CONCLUSIONS

The risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.

Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the "gold standard" for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI.

METHODS

A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up.

RESULTS

A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean -2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean -46 SD 35.7 and p-value 0.03), were associated with favorable outcomes.

CONCLUSIONS

The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study.

Dual Mobility Hip Arthroplasty: Innovative Technological Advances

The use of 3D-printed highly porous titanium acetabular cups in total hip arthroplasty (THA) is increasing. The porosity and mechanical properties of such highly porous titanium structures mimic those of natural cancellous bone, possibly allowing biological implant fixation to be improved. Recently, a 3D-printed highly porous Dual Mobility (DM) monobloc construct fully manufactured using Ti6Al4V alloy, with a titanium–niobium nitride (TiNbN) ceramic coating on the articular side to allow articulation against the mobile liner by improving the titanium vs. polyethylene tribological behavior, was introduced in THA. To the best of our knowledge, this is the first highly porous titanium monobloc DM implant on the market. The reasons for using a Ti alloy highly porous DM are multifarious: to prevent any possible adverse reactions due to the corrosion of Cobalt–Chromium–Molybdenum Alloy (CoCrMo) and Stainless Steel (SS) implants and to improve implant primary and secondary stability, particularly in cases of poor bone quality. Finally, with the introduction of an inner TiNbN ceramic coating surface, it was possible to overcome the poor tribological quality of titanium. Another interesting characteristic is this material’s higher implant radiolucency, which might facilitate the radiographic assessment of cup orientation, which can, in turn, facilitate the detection of any intraprosthetic dislocation (IPD) and the measurement of polyethylene wear, which is very important in the study of the durability of THA.

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review

(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4-6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises "debridement, antibiotics, and implant retention" (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate.

Capacitive biophysical stimulation improves the healing of vertebral fragility fractures: a prospective multicentre randomized controlled trial

BACKGROUND

Capacitively coupling electric fields (CCEF) is a method of non-invasive biophysical stimulation that enhances fracture repair and spinal fusion. This multicentre randomized controlled trial aimed to further examine the roles of CCEF in (1) the resolution of vertebral bone marrow oedema (VBME) using a follow-up MRI study and (2) pain relief, analgesic drug consumption and quality of life improvement in stimulated patients who were referred with acute vertebral fragility fractures (VFFs) compared to non-stimulated patients.

METHODS

Between September 2016 and December 2019, patients who were referred to the spine centres that participated in this multicentre randomized clinical study with acute VFFs of type OF1 or OF2 were included in the present study. All the VFFs were conservatively managed according to Good Clinical Practice. Moreover, the patients were randomized into two groups: the CCEF group received, as an adjunct to the clinical study protocol, biophysical stimulation with a CCEF device (Osteospine, IGEA) for 8 h per day for 60 days, whereas the control group was treated according to the clinical study protocol. At baseline (T0), the 30-day follow-up (T1), the 60-day follow-up (T2), and the 6-month follow-up (T3), each patient underwent clinical evaluation using the Visual Analogue Scale (VAS) for Pain and the Oswestry Disability Index (ODI). Analgesic therapy with paracetamol 1000 mg tablets for 7 days-or longer, depending on the pain intensity-was performed; patients were required to report their paracetamol consumption on a specific sheet between study day 8 to 180 days of follow-up. MRI studies of the thoracolumbar spine were performed at 0 (T0), 30 (T1) and 60 days of follow-up (T2) using a 1.5-T MRI system in all of the centres that took part in the study. For each VBME area examined via MRI, the vertebral body geometry (i.e. anterior wall height/posterior wall height and vertebral kyphosis) were assessed.

RESULTS

A total of 66 patients (male: 9, 13.63%; mean age: 73.15 years old) with 69 VFFs were included in the present study and randomized as follows: 33 patients were included in the control group and the remaining 33 patients were randomized into the CCEF group. In the CCEF group, good compliance with CCEF therapy was observed (adherence = 94%), and no adverse effects were recorded. In the stimulated patients, faster VBME resolution and significantly less vertebral body collapse during follow-up were observed compared to the control patients. Moreover, in the active group, faster pain reduction and improvement in the ODI mean score were observed. Stimulated patients also reported a significantly lower paracetamol consumption rate from the third follow-up after treatment until the 6-month follow-up. In terms of sex-related differences, in the CCEF group, VBME showed a faster resolution in male patients compared with females.

CONCLUSION

Biophysical stimulation with CCEF, as an adjunct to traditional conservative treatment, is a useful tool to hasten the VBME resolution process and prevent vertebral body deformation. These MRI findings also correlate with faster back pain resolution and quality of life improvement. From the third follow-up after treatment until the 6-month follow-up, stimulated patients reported a significantly lower paracetamol consumption than control patients, even though back pain and quality of life showed no significant differences between the two groups.

LEVEL OF EVIDENCE

II. Trial Registration Register: ClinicalTrials.gov, number: NCT05803681.

Arthroscopic inferior leaf meniscectomy of the involved anterior horn in the lateral meniscus horizontal tear via an accessary extreme far anteromedial portal

BACKGROUND

An accessory extreme far anteromedial portal can improve visualisation and ease inferior leaf meniscectomy in patients with lateral meniscal anterior horn horizontal tears. However, the therapeutic outcomes of adding an accessory extreme far anteromedial portal remain unclear. This study aimed to evaluate the clinical efficacy of adding an accessory extreme far anteromedial portal for treating lateral meniscal horizontal tears involving the anterior horns.

METHODS

This retrospective study included 101 patients with anterior horn involvement in lateral meniscal horizontal tears who underwent arthroscopic unstable inferior leaf meniscectomy between January 2016 and December 2020. The pathologies were diagnosed using physical examinations and magnetic resonance imaging. The anterior horn involved in the lateral meniscal horizontal tears was treated using inferior leaf meniscectomy. The primary endpoints were changes in the visual analogue scale, Lysholm, International Knee Documentation Committee, and Tegner scores at the final follow-up. The secondary endpoint was meniscal cure rate at 3 months postoperatively. The preoperative and postoperative functional scores were compared. The occurrence of complications was recorded.

RESULTS

All patients were followed up for an average of 4.9 ± 1.2 years (range 2.3-7.5 years). After 4 months, none of the patients experienced pain, weakness, instability, or tenderness in the lateral joint line, achieving an imaging cure rate of 98%. At the final follow-up, significant postoperative improvements were observed in the average values of the visual analogue scale score (3.5 ± 0.7 vs. 0.7 ± 0.6), Lysholm score (62.7 ± 4.4 vs. 91.8 ± 3.1), International Knee Documentation Committee score (61.9 ± 3.7 vs. 91.7 ± 9.5), and Tegner score (2.0 ± 0.7 vs. 6.1 ± 0.7). Excellent Lysholm scores were obtained in 81 patients, and good outcomes were obtained in 18 patients, with an excellent-to-good rate of 98.0%.

CONCLUSIONS

Inferior leaf resection via the accessory far anteromedial portal is a safe treatment option for the involved anterior horn in lateral meniscal horizontal tears. This approach enhances visibility and facilitates surgical procedures, with minimal complications.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Differences in the Synovial Fluid Proteome of Septic and Aseptic Implant Failure

Implant loosening is a severe complication after total joint replacement. Here, differential diagnosis between septic and aseptic cases is crucial for further surgical treatment, but low-grade periprosthetic joint infections (PJIs) in particular remain a challenge. In this study, we analyzed the synovial fluid proteome of 21 patients undergoing revision surgery for septic (eight cases) or aseptic (thirteen cases) implant failure using LC-MS/MS to identify potential new biomarkers as future diagnostic tools. Staphylococci were found in four cases, Streptococci in two cases, Serratia marcescens and Cutibacterium acnes in one case. Proteomic analysis of the synovial fluid resulted in the identification of 515 different proteins based on at least two peptides. A statistical comparison revealed 37 differentially abundant proteins (p < 0.05), of which 17 proteins (46%) showed a higher abundance in the septic group. The proteins with the highest fold change included the known marker proteins c-reactive protein (7.57-fold) and the calprotectin components protein S100-A8 (4.41-fold) and protein S100-A9 (3.1-fold). However, the protein with the highest fold change was leucine-rich alpha-2-glycoprotein 1 (LRG1) (9.07-fold), a currently discussed new biomarker for inflammatory diseases. Elevated LRG1 levels could facilitate the diagnosis of PJI in the future, but their significance needs to be further investigated.

Mid-term results of titanium-titanium modular neck femoral stem in primary total hip arthroplasty

BACKGROUND

Modular neck femoral stems are advantageous because they can accurately restore the ideal hip geometry using various options in terms of offset, length, and version. However, there are concerns regarding junctional problems. Despite several reports on such issues, there is a lack of study on mid- to long-term results of these stems. The current study evaluated the mid-term results of patients who underwent primary total hip arthroplasty using a titanium-titanium (Ti-Ti) modular neck femoral stem.

METHODS

In total, data on 47 hips (42 patients) that could be followed-up for ≥ 5 years after primary total hip arthroplasty using the Ti-Ti modular neck femoral stem from 2011 to 2015 were reviewed. There were 22 male and 20 female patients, and their mean age was 56.3 (range: 31-76) years. The mean follow-up period was 8 (range: 5-12) years. Functional and radiological outcomes, complications, and reoperations were investigated. In addition, we conducted a comparative analysis of the outcomes between those who underwent surgery using the Ti-Ti modular neck femoral stem and 41 hips (35 patients, 19 males and 16 females) that underwent primary total hip arthroplasty using nonmodular femoral stems as a control.

RESULTS

In all Ti-Ti cases, the mean Harris Hip Scores were 50.6 (range: 6-59) preoperatively and 92.7 (range: 78-99) at the last follow-up (P < 0.001). Regarding the neck component's modularity, straight neck components were used in all Ti-Ti cases, and an anteverted or a retroverted neck was not used in any case. Stem revision was performed in one hip due to aseptic loosening. One hip underwent open reduction and internal fixation due to periprosthetic fracture without stem loosening. There were no cases of osteolysis and periprosthetic joint infection and clinically detectable junctional problems. The stem survival rate, with any stem revision as the endpoint, at 12 years was 96.6%. No significant difference was observed in the functional and radiological outcomes beween the Ti-Ti and nonmodular groups.

CONCLUSIONS

The Ti-Ti modular neck femoral stem had comparable results with broadly used nonmodular femoral stems; hence, it can be a reliable option in primary total hip arthroplasty. However, in terms of the modularity itself of the modular neck femoral stem, whether the modular neck femoral stem is useful in uncomplicated primary total hip arthroplasty is unclear.

Successful Management of Impending Skin Necrosis After a Posterolateral Knee Dislocation

Incarcerated medial soft tissue after posterolateral knee dislocations has been described, but limited information pertaining to the etiology and management of cutaneous injuries from incarceration exists. We present the case of a 64-year-old man, where reduction of a posterolateral knee dislocation resulted in incarceration of medial ligamentous structures and impending skin necrosis. The patient avoided full-thickness skin necrosis, which could have complicated treatment options. Careful consideration of the soft-tissue envelope of the knee for preventing additional skin injury in the perioperative period should be considered to potentially avert additional necrosis in patients with a 'pucker' sign after knee dislocations.

Risk factor analysis of femoral avascular necrosis after operation for Tönnis grade IV developmental dysplasia of the hip

PURPOSE

We explored the risk factors for avascular necrosis (AVN) after surgery using open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV developmental dysplasia of the hip (DDH).

METHODS

In this retrospective study, we collected data of patients with Tönnis grade IV DDH treated with open reduction and pelvic osteotomy combined with femoral osteotomy from January 2012 to May 2020. The patients were divided into the AVN group and non-AVN group using the Kalamchi-MacEwen classification system. The clinical and imaging data of the two groups were collected, and the possible risk factors were included in the analysis. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors and odds ratios of AVN.

RESULTS

In all, 254 patients (mean age; 2.6±0.9 years, 278 hips) were included. The mean follow-up time was 3.8±1.5 years. A total of 89 hips (32%) were finally classified as AVN (Kalamchi-MacEwen II-IV). Univariate analysis showed significant associations with AVN for age (p=0.006), preoperative femoral neck anteversion (FAV) (p<0.001), femoral osteotomy length to dislocation height ratio (FDR) <1 (p<0.001), and the epiphyseal ossific nucleus diameter to the neck diameter ratio (ENR) <50% (p=0.009). Multivariate logistic regression analysis showed that only excessive preoperative FAV (OR: 1.04; 95% CI: 1.02-1.05; p<0.001) and FDR<1 (OR: 3.58; 95% CI: 2.03-6.31; p<0.001) were independent risk factors for femoral head necrosis.

CONCLUSION

Excessive preoperative FAV and FDR<1 are important risk factors for femoral AVN after open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV DDH. For children with DDH with high dislocation and excessive FAV, clinicians should fully evaluate their condition and design more personalized treatment programs to prevent AVN.

Outcomes and complications of Total Hip Arthroplasty in patients with a pre-existing pathologic spine-hip relation. A systematic review of the literature

BACKGROUND

There has been a growing interest in pathologic spine-hip relations (PSHR) in current literature, with the aim of reducing the risk of prosthetic impingement, dislocation, and edge loading in total hip arthroplasty (THA). The primary objective of this review is to determine the effect of different PSHR on primary THA outcomes and complication profile. The secondary objective is to stratify the risk of different subgroups of PSHR patients.

METHODS

A systematic review of the literature was performed in accordance with PRISMA guidelines. Randomised controlled trials, comparative cohort studies and case-control studies comparing outcomes and complication rates of primary THA in patients with and without a PSHR (spinal fusion; degenerative spinal conditions determining stiff spine and/or spinal misalignment) were included. The quality of the included studies and the risk of bias were assessed. The revision rate, complications, and clinical and radiological data were analysed. Complications included: aseptic loosening (AL), periprosthetic joint infections (PJI), hip dislocations and periprosthetic fractures (PF).

RESULTS

Fifteen articles were included with 3.306.342 THAs. The mean follow-up (FU) was 31.4 ± 21.7 months. The population was divided into three subgroups: spinal fusion patients (48.315 THAs); non-fused patients with spinal stiffness (106.110 THAs); non-fused patients with normal spines (3.151.917 THAs). A statistically significant risk stratification was observed about dislocation rate (5.98 ± 6.9% SF, 3.0 ± 1.9% non-SF Stiff and 2.26 ± 1.4% non-SF; p = 0.028). Similarly, about THA revision rate, a statistically significant risk stratification was also observed (7.3 ± 6.8% SF, 6.4 ± 3.1% non-SF Stiff and 2.7 ± 1.7% non-SF; p = 0.020). No statistically significant difference was observed when analysing AL, PJI and PF.

CONCLUSION

A statistically significant risk stratification of dislocation and revision rate was observed in the different PHSR, as theorised by the Bordeaux classification. Fused patients present a higher risk, degenerated and/or stiff spine an intermediate risk and mobile spines a lower risk profile. A standardised approach to THA candidate patients must consider the possible PSHR to improve clinical outcomes and reduce adverse events of THA.

Pelvic flexion/extension and its impact on functional acetabular alignment and stability following total hip replacement

PURPOSE

Dislocation following total hip arthroplasty (THA) remains a significant clinical problem and can occur even with optimal implant alignment. We hypothesized that different patterns of pelvic flexion/extension (PFE) during daily activities may influence acetabular alignment and contribute to impingement and instability following THA. Recently, there has been an increased interest in spinopelvic alignment and its impact on THA. Therefore, this study aimed to identify different patterns of PFE that could be predictive of instability following THA.

METHODS

A range of motion (ROM) simulator was used to demonstrate the effects of different patterns of PFE on ROM and impingement. The findings were applied to PFE measurements obtained from 84 patients in standing and sitting positions.

RESULTS

Three different categories of PFE were identified: normal, hypermobile, and stiff. ROM simulator revealed that changes in PFE had affected ROM and impingement significantly. Patients in the stiff pelvis category, even with "optimal" implant alignment, were more susceptible to implant impingement.

CONCLUSIONS

The different patterns of PFE during daily activities could affect acetabular alignment and stability following THA. We propose a classification system that can identify different types of PFE and predict their effects on the stability of prostheses following THA. Hence, we believe that patients with unfavorable PFE may require modified cup alignment.

Hip-spine relationship: clinical evidence and biomechanical issues

The hip-spine relationship is a critical consideration in total hip arthroplasty (THA) procedures. While THA is generally successful in patient, complications such as instability and dislocation can arise. These issues are significantly influenced by the alignment of implant components and the overall balance of the spine and pelvis, known as spinopelvic balance. Patients with alteration of those parameters, in particular rigid spines, often due to fusion surgery, face a higher risk of THA complications, with an emphasis on complications in instability, impingement and dislocation. For these reasons, over the years, computer modelling and simulation techniques have been developed to support clinicians in the different steps of surgery. The aim of the current review is to present current knowledge on hip-spine relationship to serve as a common platform of discussion among clinicians and engineers. The offered overview aims to update the reader on the main critical aspects of the issue, from both a theoretical and practical perspective, and to be a valuable introductory tool for those approaching this problem for the first time.