Introduction: Knee joint stability is influenced by force distribution and ligament structures. High Tibial Osteotomy (HTO) treats knee deformities and redistributes load, reducing further invasive procedures. High Tibial Osteotomy (HTO) is a well-established procedure for addressing knee instability, particularly in cases involving ligament deficiencies such as ACL and PCL insufficiencies. This systematic review aims to evaluate the clinical outcomes and long-term efficacy of HTO in improving knee stability and function. Methods: A systematic literature search was conducted using Cochrane Central, PubMed, MEDLINE, and ProQuest databases for studies published between 2000 and June 2024. Eligible studies included human subjects with at least six months of follow-up and focused on HTO for knee instability. Exclusion criteria included animal studies, non-knee joint studies, and reviews. Data on patient demographics, follow-up duration, subjective and objective outcomes, and complications were extracted. Results: Out of 536 studies identified, 11 met the inclusion criteria, encompassing 303 patients. Combining HTO with ACL or PCL reconstruction significantly improved both subjective instability and objective measures, including Lachman and Pivot Shift test grades. Patient satisfaction was high, and functional scores such as Lysholm and Tegner improved markedly. The incidence of complications was low, with minor issues such as infections and delayed union, and no reported graft failures. Conclusion: HTO, particularly when combined with ligament reconstruction, effectively treats knee instability due to ACL or PCL deficiency. The procedure demonstrates strong mid- to long-term outcomes, high patient satisfaction, and a low rate of complications. It remains a viable option for patients with knee instability.

Introduction: Revision Total Knee Arthroplasty (RTKA) is complex, and induced bone loss might endanger implant fixation and joint stability. Intramedullary stems improve fixation throughout stress redistribution. The current study aims to compare the performance of short tibial stems with long tibial stems, investigating their intermediate-term radiographic and survival outcomes in RTKA. The main hypothesis is that the two types of tibial stems would exhibit similar complication and revision rates in mid-term follow-up. Methods: Patients who underwent RTKA for all causes in a specialized arthroplasty center from 2010 to 2022 with minimum 2-year follow-up were included in this study. Patients receiving mega prosthesis or implants associated with sleeves or cones were excluded. The final groups consisted of 234 knees: 110 patients with short stems (SS) and 124 with long stems (LS). The mean age at surgery was 65.96 ± 8.73 years in SS and 67.07 ± 8.64 years in LS. The mean Body Mass Index (BMI) was 28.95 is SS and 30.88 in LS (p < 0.05). The average follow-up for SS group was 4.24 years and for LS 5.16 years (p < 0.05). Results: Complications and re-revisions did not differ significantly between two groups (p > 0.05). Pathological radiolucency was present in 20.91% in SS group and 33.87% in LS group (p < 0.02). Time-to-re-revision was shorter in SS group and occurred at a mean of 3.1 years, while LS failed at a mean of 5.1 years (p < 0.001). Conclusions: The SS and LS may be comparable in terms of complications and re-revision. SS significantly fails almost 2 years earlier than long stem (p < 0.001). Additionally, there is a higher tendency for re-revision due to loosening in patients who present pathological radiolucency in SS group. To obtain the benefits of short stem and improve the longevity of the construct; adjuvant zone II (metaphyseal) fixation might be the clue.

Background: Hinge fracture on the lateral part of the tibia (LHF) is a common complication of medial Open Wedge High Tibial Osteotomy (OWHTO). Many factors have been described as risks for these fractures, but no study has compared an osteotome or an oscillating saw to prevent LHF following OWHTO. Methods: This “propensity-score-matched” (PSM) study was conducted from data obtained in the literature from 1974 to November 2024. A total of 10,368 knees with OWHTO were identified. After 1:1 matching based on correction amount, posterior slope change, surgeon’s experience, the osteotome and oscillating groups comprised 2760 knees each. Results: Among the 5520 knees of the PSM population, the prevalence of LHF was 6.1% in the osteotome alone group (168 cases), and 22% in the oscillating saw group (607 cases). The osteotome group had a significant lower prevalence of hinge fracture than the oscillating saw group (OR, 0.23; 95% CI, 0.19 to 0.27; p < 0.0001) and a lower rate of clinically relevant hinge fractures with revision (OR, 0.34; 95% CI, 0.25 to 0.45; p < 0.001. Discussion: The osteotome may be an appropriate method for preventing hinge fractures following OWHTO.

Purpose: The primary aim of this study is to determine the rectus abdominis tendon (RAT) insertional anatomy and consequently clarify the extension of secure mobilization of the tendon from the pubic bone in the setting of anterior approaches in pelvic and acetabular reconstruction surgery. Materials and methods: Eleven fresh frozen cadaveric pelvises were dissected by two fellowship-trained orthopaedic trauma surgeons utilizing the anterior intrapelvic approach (AIP). The RAT at the pubic body was dissected, and its footprint on the pubic bone was defined, marked, and measured. Results: Nineteen (19) RAT insertions were analyzed. The average total medial vertical length was 33 mm (range 26–42 mm), and the average total lateral vertical length was 36.5 mm (range 26–46 mm). The total width of the proximal insertion on both sides was measured at an average of 20.42 mm (range 14–24 mm). The average width of the tendon at the transition area between the cranial and caudal areas of the pubic bone was 16.45 mm (range 12–22 mm). The average distal insertion width of the RAT was less than the proximal and middle widths, measuring 10.45 mm (range 8–13 mm). Conclusion: The tendon can be safely mobilized up to an average total medial vertical length of 33 mm (and in no case more than 42 mm) and to an average total lateral vertical length of 36.5 mm (and in no case more than 46 mm). This piece of anatomical information will equip orthopaedic surgeons with a better understanding of the insertional anatomy of the RAT and subsequent safer surgical release when performing anterior approaches to the pelvic ring.

Introduction: Extraarticular deformity (EAD) with knee arthritis is a complex condition involving tri-planar bone deformity with pathological malalignment and chronic soft tissue contracture or laxity in the knee joint. Intraarticular correction by TKA, which was previously performed with conventional manual jig by mechanical alignment technique, had its limits and difficulties especially extensive soft tissue release and risk of jeopardizing the collateral ligaments. Robotic technology allows for reproducible and precise execution of surgical plan and allows adjustment to various new personalised alignment philosophy including functional alignment (FA). FA technique involves the adjustment of components positioning that least compromise the soft tissue envelope while restoring the limb alignment and joint obliquity to create a balanced knee. The aim is to study the outcome of intra-articular correction by robotic assisted TKA using Functional Alignment (FA) technique. Methodology: This is a single surgeon series of 8 patients with extraarticular deformity who underwent robotic assisted total knee arthroplasty (TKA) with FA technique. Soft tissue release was gradually released and followed by adjustments of implant positioning in order to achieve a balanced medio-lateral gap. Results: Postoperatively, the lower limb alignment of all patients were restored within 6° (mean 4.54°) based on functional alignment boundaries. Knee phenotype and joint line obliquity (JLO) were restored in comparison to contralateral lower limb. There were 6 varus and 2 valgus malalignment. 7 patients were implanted with posterior stabilized implants while 1 was implanted with cruciate retaining implant. Arc of knee flexion and extension improved (P = 0.002). There was a large postoperative improvement in the Knee Society Score (KSS) (P < 0.001). Discussion: Intraarticular correction by TKA for EAD with knee arthritis is technically reliable with robotic technology. It allows intraoperative adjustment following functional alignment philosophy, thereby, restoring pre-arthritic alignment, knee phenotype and joint line obliquity.

Purpose: To clarify the location of the popliteal artery (PA) is relative to the tibial osteotomy plane in patients with medial and lateral unicompartmental knee osteoarthritis (KOA) undergoing UKA. Methods: Preoperative MRI and postoperative radiographs obtained from 50 patients with unicompartmental KOA who underwent fixed-bearing UKA were analyzed. The amount of tibial resection was determined from the surgical records, and a line was drawn parallel to the tibial posterior tilt angle on the sagittal MR image to create a virtual tibial cut line. The tibial resection width measured from the anteroposterior image of the postoperative radiograph was projected onto the transverse plane containing the intersection between the virtual tibial cut line and the posterior tibial cortex, after which a line was drawn parallel to the medial or lateral intercondylar ridge. We then determined whether the PA was within an extension of the osteotomy area. The shortest distance (Distance 1) between the posterior tibial cortex and the PA within the osteotomy area was measured. In addition, the shortest distance between the line extending the osteotomy posteriorly and the PA was measured (Distance 2). Results: The medial UKA (group M) and lateral UKA (group L) group comprised 41 and 9 cases. The percentage of PA located behind the osteotomy plane was significantly higher in group L than in group M [6/9 knees (66.7%) vs. 2/41 knees (4.9%); P < 0.001]. The distance 1 was 12.6 (4.3) mm in group M and 7.9 (3.7) mm in group L (P = 0.004). The distance2 was 11.1 (4.9) mm in group M and 2.6 (3.5) mm in group L (P < 0.001). Conclusion: During lateral UKA, the PA was often located behind the tibial osteotomy plane and close to the posterior tibial cortex. Nearly 5% of medial UKAs, the artery was located behind the osteotomy plane. Level of Evidence: Retrospective comparative LEVEL III study.

Purpose While increased posterior tibial slope (PTS) is a concern post-medial open wedge high tibial osteotomy (MOWHTO), the ability of distal tuberosity osteotomy (DTO) to maintain postoperative PTS after cyclic loading remains unverified. This study aims to determine whether PTS alterations significantly differ between DTO and MOWHTO following cyclic loading. Methods: Biomechanical evaluations were conducted on thirty porcine tibias using MOWHTO and DTO, with and without an anterior-posterior (AP) screw. To investigate PTS changes, cyclic testing was carried out for MOWHTO and DTO. Displacement along the mechanical axis during cycles 10th, 100th, 500th, 1000th, 1500th and 2000th, variations in anterior and posterior gaps after 2000 cycles and increased PTS after 2000 cycles, were compared across the three groups. The displacement was evaluated by repeated-measures analysis of variance (ANOVA), and changes in AG and PG and increased PTS were evaluated by one-way ANOVA. The sample size for α and β errors were <0.05 and <0.20, and the effect size was 0.60 for one-way ANOVA and 0.46 for repeated-measures ANOVA. Results: There were no significant differences in displacement and anterior gap changes among the groups. A significant difference was observed in the posterior gap changes (P < 0.001) and increased PTS (P = 0.013) among the groups. Post hoc analysis indicated substantial disparities between MOWHTO and DTO without the AP screw (P = 0.035), as well as between MOWHTO and DTO with the AP screw (P = 0.021) concerning the increased PTS. Conclusion: After cyclic loading, MOWHTO exhibited a notably smaller PTS change than DTO regardless of the presence of an AP screw.

Purpose: Medial meniscus posterior root tears (MMPRT) pull-out repair aims to restore the meniscus’ anatomical structure. Different implants are utilized for thread fixation in the pull-out repair technique for MMPRT. However, biomechanical evidence comparing the fixation strengths of these implants remains unavailable. This study investigated the tensile strength of three fixation implants in porcine knee models of MMPRT pull-out repair. Methods: This study categorized 30 porcine MMPRT models undergoing pull-out repair into three groups (10 specimens each) based on the implant utilized for fixation, including double spike plate, metallic interference screw (IFS), and resorbable IFS fixed group. A tensile tester was used to track the suture wire threaded to the medial meniscus anterior root. The displacement length was recorded after 10 and 20 loading cycles (10–30 N, 100 mm/min cross-head speed). Each specimen was then stretched to failure (50 mm/min cross-head speed), failure modes were recorded, and structural properties (maximum load, linear stiffness, elongation at failure, and elongation at yield) were compared. Fisher’s exact test and one-way analysis of variance were utilized to assess the differences. Results: No significant differences in displacement length, upper yield load, maximum load, linear stiffness, elongation at yield, elongation at failure, and frequency of failure mode were observed between the three groups. Conclusion: All implants were comparable in terms of fixation strength. Thus, resorbable interference screws may be particularly useful in this technique and does not require implant removal surgery. Level of evidence: IV.

Introduction: The arthroscopic repair of a massive rotator cuff tear could be surgically challenging. There is a continuous argument regarding the best surgical technique and suture configuration used to treat massive rotator cuff tears. The purpose of this study was to assess the in vitro strength of the new double Mason-Allen suture and compare it to the commonly used other suture configurations. Methods: Twenty-five fresh sheep shoulders were randomly divided into five equal groups. Each group had their infraspinatus tendons cut and repaired with one of five suture configurations (simple, horizontal mattress, Mason-Allen, modified Mason-Allen, and double Mason-Allen) using Arthrex® 1.3 mm suture tape. The specimens were fixed to the test apparatus through their scapulae and hung with the repair tape to Sartorius® precision balance with sequential load increments till failure. The load to failure was measured for each of the five suture configurations. Results: Study data found the double Mason-Allen configuration to have the highest mean load to failure 423.30 ± 23.05 (Newtons), followed by modified Mason-Allen, Mason-Allen, horizontal mattress, and simple suture respectively. Conclusion: The double Mason-Allen repair configuration has the highest load to failure compared to the other known suture configuration to repair rotator cuff tears.

Introduction: Limb salvage surgery in children following bone sarcoma resection is a challenging problem because of the small size of the bones, the lack of appropriate size-matched implants, and the risk of limb-length discrepancy once skeletal growth is complete, secondary to the loss of the epiphyseal plate. Although several reconstruction options are available in children with bone sarcomas, such as vascularized fibula, massive bone allograft, extracorporeal devitalized autograft, endoprosthesis, and allograft-prosthesis composite, a consensus has not been reached on the best reconstruction method. The purpose of the present study is to propose an algorithm for reconstruction after resection of bone sarcomas in children. Methods: In this review, we analyzed reports on limb reconstruction in children following treatment for bone sarcoma, to provide a comprehensive overview of the different reconstruction options in children with bone sarcomas, the outcomes, and the risks and benefits of the different surgical approaches. Results: Despite a high risk of complications and the necessity for limb-lengthening procedures, prosthetic or biological reconstructions seem to achieve good functional outcomes in children with bone sarcoma. The use of massive bone graft seems to be recommended for intercalary reconstructions, with a free vascularized fibular graft for long defects, while for osteoarticular reconstruction a modular or expandable prosthesis or an allograft–prosthesis composite seems to have good results. For reconstruction of the proximal humerus, modular prosthesis or allograft-prosthesis composite are more commonly used than expandable prosthesis since there are fewer functional constraints related to possible limb-length discrepancy on the upper limb compared to the lower limb. Discussion: We discuss the advantages and limitations of the different available surgical options for bone reconstruction following tumor resection in children and propose an algorithm of potential surgical treatments for children with bone sarcomas of the extremities.

Hip arthroscopy is a rapidly evolving field in orthopedics, offering diagnostic and therapeutic benefits for a range of hip pathologies. This review outlines a comprehensive guide to initiating hip arthroscopy safely and effectively using evidence-based practices. Optimal surgical outcomes depend on correct indications for surgery, in particular in the presence of borderline dysplasia and degenerative joint diseases. Proper patient counseling and setting realistic expectations are crucial for satisfactory outcomes and recovery. Physical examination, radiographs, MRI, and CT scans are essential for accurate diagnosis. In case of diagnostic uncertainty, the use of intra-articular injections can help confirm the diagnosis before surgery. Techniques for hip arthroscopy include central compartment first, peripheral compartment first, and outside-in approaches. Each technique has advantages, and the optimal approach depends on the specific case. Finally, Proper operating room setup, meticulous patient positioning, and precise portal placement are critical for a successful procedure. A thorough understanding of the safe zone anatomy for portal placement is essential to minimize the risk of neurovascular complications. In conclusion, this manuscript provides a detailed, evidence-based framework for starting hip arthroscopy, emphasizing the importance of technical proficiency, patient selection, and a multidisciplinary approach to ensure patient safety and procedure efficacy.

Introduction: The lesser trochanter profile (LTP) method is an intraoperative fluoroscopic technique that can assess the femoral version and limit malrotation. The purpose of this study was to directly assess the accuracy and reliability of the LTP method, as well as determine the incidence of malrotation produced by this technique. Methods: Three groups of observers (fellowship-trained orthopedic surgeons, orthopedic residents, and medical students) utilized the LTP method to replicate pre-imaged rotation angles on a cadaveric femur bone. Recorded outcomes include rotational error and number of attempts. Accuracy and interobserver reliability were assessed by rotational error and the interclass correlation coefficient (ICC), respectively. Results: Accuracy was within 3° for all three groups. ICC between each group was greater than 0.99. There was no statistical difference between the accuracy of fellowship-trained surgeons, orthopedic residents, and medical students. Medical students on average required more attempts to obtain their final image compared to fellowship-trained surgeons. There was no statistical difference in the number of attempts between residents and fellowship-trained surgeons. Conclusion: None of the LTP measurements were greater than 15°, the clinical threshold for malrotation. The average error of the observers was less than 3°, demonstrating that the LTP is an effective method of assessing the femoral version. There was no statistically significant difference between the observers, indicating that this technique is reliable and easy to use. Ultimately, the LTP method is easily reproducible for surgeons to avoid femoral malrotation.

Background: Reverse shoulder arthroplasty (RSA) is popular for the treatment of degenerative glenohumeral joint disease. Bone remodeling around the humeral stem related to stress shielding (SS) has been described. This review focuses on the specific radiological characteristics, risk factors, and clinical consequences of SS in RSA. Methods: A meticulous review was conducted of articles published between 2013 and 2023. Data on the definition, risk factors, and clinical impact of stress shielding were recorded. Results: Twenty-eight studies describing 2691 patients who had undergone RSA were included. The mean age of patients ranged from 63 to 80 years with mean follow-up periods of 12 months to 9.6 years. The prevalence of SS reached up to 39% at a 2-year follow-up. Females and elderly are typically at higher risk due to osteopenia. SS was more frequent with the use of long stems(>100 mm) compared to short stems(<100 mm). Stem design, onlay or inlay, and neck-shaft-angle did not influence SS. Frontal misalignment and a high filling ratio are riskfactors for SS. Biological factors also contribute to SS, associated with scapular notching. No correlation was found between SS and clinical outcomes. Conclusions: SS is common in patients with cementless implants after RSA, especially in female and elderly patients. It can be limited by implanting stems with a low diaphyseal filling-ratio, in correct coronal alignment. Risk factors for polyethylene debris, primarily scapular notching, should be avoided. The authors found no clinical consequences of stress shielding, but longer-term follow-up studies are required to confirm these findings.

Introduction: STAR (Superior Transverse Anatomic Reconstruction), a piriformis-preserving posterior approach, has not been extensively studied. Our study aimed to assess the STAR approach’s safety and efficacy by recording postoperative complication rates and measuring implantation accuracy in a single surgeon prospective cohort with a mean follow-up of two years. Methods: The study involved 522 patients with elective primary or complex primary total hip arthroplasty (THA) performed by a senior surgeon using the STAR approach between 2019 and 2023. 63.6% of the patients were female. The mean patients’ age was 65.6 years. 19.5% of the procedures were primary complex THAs. The mean follow-up and length of stay were 2.13 years and 1.50 days. The ratio of uncemented to hybrid and standard to dual mobility liner THAs were 3:2 and 4:1. Fifty-eight patients received blood transfusions. All patients followed the same postoperative protocol. Two physicians not involved in surgery collected clinical and radiological data. Efficacy was defined as measuring the cup inclination and anteversion, stem alignment, and leg length discrepancy (LLD) using the one-month postoperative standardised supine anteroposterior pelvic X-rays. The postoperative complication rate, including dislocation and infection, defined safety. Results: The mean cup inclination and anteversion were 42.80 (±4.9) and 19.90 (±8.9), respectively. 97.5% of the stems were placed in neutral and 2.5% in varus position. The mean LLD was 3.3 ± 6.3 mm. A single deep infection was managed with two-stage revision with no recurrence, and an early traumatic dislocation in an 80-year-old woman was managed successfully with closed reduction and hip spica. Three superficial wound infections were treated with oral antibiotics. Discussion: The STAR approach is safe and has demonstrated excellent early-to-mid-term efficacy profile outcomes. The unobstructed acetabular and femoral intraoperative view facilitated optimal implant positioning and contributed to excellent dislocation outcomes in combination with piriformis preservation.

Background: Treatment of patients with Crowe type III and IV dislocated hips is challenging because of the hip deformity in these patients. In addition to the usual total hip replacement, shortening and reduction of the femur are often required. We herein report on our surgical technique using a monoblock cylindrical cementless stem and a direct lateral approach. Methods: This study included patients with a diagnosis of severe developmental dysplasia of the hip (Crowe types III and IV) who underwent primary total hip arthroplasty at our hospital from August 2019 to January 2022. Eleven hips of seven patients were treated. All patients underwent horizontal osteotomy using a monoblock cylindrical cementless stem and a direct lateral approach. Complications such as dislocation, infection, and implant dropout were evaluated. In addition, the clinical assessment included the hip range of motion at the last observation and hip function based on the Japanese Orthopaedic Association (JOA) hip score and the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). Results: The average operation time was 224 min (range, 194–296 min), and the average bleeding amount was 396.1 g (range, 20–1010 g). The main complications were acetabular implant dislocation, postoperative dislocation, intraoperative arterial injury, intraoperative proximal femoral fracture, subsidence of femoral implant. and postoperative pulmonary infarction, which occurred in one patient each. Conclusion: Total hip arthroplasty for Crowe type III and IV hips is associated with various surgical technical difficulties because of its anatomical characteristics. While patients with severe osteoporosis are contraindicated, the use of a cylindrical monoblock cementless stem and the direct lateral approach makes it possible to simplify the procedure for shortening the femur and increase the indications for surgery. Level of evidence: Therapeutic Level Ⅳ.

Introduction: This study aimed to compare the revision rate and long-term survival between two generations of uncemented dual mobility cup (DMC) from the same manufacturer in primary total hip arthroplasty (THA) at a minimum follow-up of 10 years. Methods: This retrospective monocentric study included all THA performed with an uncemented DMC from the same company. The cohort included 150 patients with 22 first-generation DMC and 128 second-generation DMC. The coating of the second generation was a double-coating Plasma spray of Titanium and Hydroxyapatite (HAP), compared to the coating of alumina and HAP for the first generation. The mean follow-up was 14.2 ± 1.2 years. The mean age was 76.0 ± 10.1 years. The Harris hip score (HHS), complications, and revisions were collected at the last follow-up. Ten- and fifteen-year Kaplan-Meier survival was calculated. Results: At the last follow-up, the mean HHS was 83.2 ± 9.1. There were two acetabular loosenings with the old coating (9.1%) and one case with the new one (0.78%) (p = 0.056). There was one extra-prosthetic dislocation (0.67%) and one postoperative infection (0.67%). Survival without acetabular revision at 10 and 15 years was 90.9% for the 1st generation and 99.2% for the 2nd generation (p = 0.009). Conclusion: Survival without acetabular revision was significantly higher at 10 and 15 years of follow-up with the second generation of DMC with plasma-sprayed titanium and HAP coating compared to the first generation of DMC coat. The dislocation was uncommon, thanks to the dual mobility concept. This second generation of uncemented DMC can be safely used in primary THA.

Introduction: Simultaneous bilateral total hip arthroplasty (THA) has demonstrated similar clinical outcomes to staged bilateral THA. However, there is scarce data regarding the early postoperative complications. This study compares simultaneous to staged bilateral THA with the direct anterior approach (DAA) regarding early complications and revision surgeries. Methods: This retrospective case-control study included all bilateral THAs, performed by DAA between 2013 and 2021 with a minimum follow-up of 6 months. A total of 264 THAs (132 patients) were identified [simultaneous group (1T): 58 patients; staged group (2T): 74] with a mean follow-up of 54 months. Complications and revisions, clinical outcomes, and days off work were assessed at the last follow-up. Moreover, blood loss was evaluated by the modified method of Mercuriali and Inghilleri. Results: Blood loss was higher in the 1T group (1003 mL 1T vs. 740 mL 2T; p < 0.001) but there was no significant difference in transfusion rates (5% 1T vs. 3% 2T; p = 0.4). There were no complications in 1T, while the complication rate was 5.2% (n = 6) in 2T (p = 0.012). There were 5 revisions in the 2T group, including 2 debridements with polyethylene exchange and implant retention for early infections, 2 revisions for aseptic loosening in the same patient, and 1 revision due to fracture. Postoperative pain on D3 was equivalent in both groups (4.2 1T vs. 4.3 2T; p = 0.79). The improvement in function according to the HHS at 2 months was better in the 1T group, but not significant (36.8 1T vs. 32.9 2T; p = 0.05). The total number of days off work was significantly higher in the 2T group (82.6 days vs. 178.8; p = 0.025). Discussion: Simultaneous bilateral THA with the DAA seems to be a safe procedure, with no risk of increased early postoperative complications when compared to the staged procedure with similar functional outcomes and significantly fewer complications and days off work.

This review brings together a multidisciplinary, multinational team of experts to discuss the current state of knowledge in the detection and treatment of hip displacement in cerebral palsy (CP), a global public health problem with a high disease burden. Though common themes are pervasive, different views are also represented, reflecting the confluence of traditional thinking regarding the aetiology and treatment of hip displacement in CP with emerging research that challenges these tried-and-true principles. The development of hip displacement is most closely related to gross motor function, with radiographic surveillance programs based on the Gross Motor Function Classification System (GMFCS), the goal being early detection and timely treatment. These treatments may include non-operative methods such as abduction bracing and Botulinum Neurotoxin A (BoNT-A), but outcomes research in this area has been variable in quality. This has contributed to conflicting opinions and limited consensus. Soft tissue lengthening of the hip adductors and flexors has traditionally been employed for younger patients, but population-based studies have shown decreased survivorship for this treatment when performed in isolation. Concerns with the identification of hip displacement in very young children are raised, noting that early reconstructive surgery has a high recurrence rate. This has prompted consideration of viable minimally invasive alternatives that may have better success rates in very young children with CP, or may at least delay the need for osteotomies. Recent reports have implicated the role of abnormal proximal femoral growth and secondary acetabular dysplasia as a primary cause of hip displacement, related to ambulatory status and abductor function. As such, guided growth of the proximal femur has emerged as a possible treatment that addresses this purported aetiology, with promising early results.

Purpose: The current study aimed to investigate the correlation between the grade of radiographic hip osteoarthritis (OA) and the fracture pattern observed in fragility fractures of the proximal femur. The information may help in cases of occult hip fractures. Methods: In this retrospective study all 448 patients treated with fragility fractures of the proximal femur in the years 2014–2018 were included. Patients were allocated into two groups: Group I) intracapsular (femoral neck) fractures and Group II) extracapsular (pertrochanteric and subtrochanteric) femoral fractures. The radiographic grade of OA was determined according to Kellgren and Lawrence’s classification. One single observer examined all radiographs. Results: Patients’ age ranged between 52 and 104 years with a mean of 80.0 years. There was a significant difference in mean age between the two groups (76.9 years intracapsular vs. 83.1 years extracapsular fractures). A total of 250 (55.8%) fractures were intracapsular (femoral neck) and 198 (44.2%) were located extracapsular (pertrochanteric, subtrochanteric). A significant correlation between the degree of OA to fracture pattern was observed: Higher degrees of OA were related to extracapsular fractures and lower degrees of OA to intracapsular fractures. Conclusion: The results of this study support the hypothesis that hip osteoarthritis affects the fracture pattern in proximal femur fractures. More severe hip OA is associated with extracapsular fractures that can be treated surgically with lower complication rates compared to intracapsular fractures.

Background: Hydroxyapatite (HA) coated femoral stems were introduced to enhance the biological fixation at the implant-bone interface, aiming to increase the longevity and survival of the prostheses. We aimed to assess the long-term outcomes of an HA ceramic (HAC) coated stem in primary total hip arthroplasty (THA), assess the stem survival, and clinically evaluate the patients using patient-reported outcome measures (PROMs) and radiological evaluation of stem osseointegration. Patients and methods: This was a prospective evaluation of a retrospective cohort of 385 patients (442 hips) who underwent primary THA between June 2008 and December 2018. The mean age was 63.83 years (range, 30–82 years). During the follow-up duration, 23 patients died, and 36 patients (38 hips) were lost to follow-up. Prospective data collected for 326 patients (381 hips) was used to evaluate stem survival with the Kaplan–Meier method using aseptic loosening or any revision as the endpoint. Clinical evaluation was done using the EuroQol five-dimension (EQ-5D) scoring system and PROMs using the Oxford Hip Score (OHS) and Merle D’Aubigne Postel (MDP) score. Radiological assessments were performed using the Engh radiological criteria for stem osteointegration. Results: The mean follow-up duration was 9.39 years (range, 4–14.5 years). The survival of the HAC-coated femoral stem was 100% (95% confidence interval [CI], 96.7–100%) at 14 years with aseptic loosening as the endpoint, and 98.9% (CI, 96.7–100%) at 14 years with stem revision for any reason as the endpoint. The mean OHS was 44.5 (range, 30–48), and the mean MDP score was 15.87 (range, 10–18). Radiological evaluations showed full osseointegration of all stems. Conclusion: This HAC-coated femoral stem has shown excellent survivorship, functional outcomes, and full osseointegration at the final follow-up.

Introduction: To prevent infection after limb-sparing surgery for primary malignant bone tumors, it is important to cover the megaprosthesis with muscle tissue that has sufficient blood flow. Coverage with a lateral gastrocnemius flap has been reported in cases of distal femoral replacement in which the vastus lateralis and vastus intermedius muscles have been resected; however, the risk of peroneal nerve palsy is reportedly high because the muscle flap passes near the peroneal head. This study was performed to examine the postoperative outcomes of patients with primary malignant bone tumors of the distal femur who underwent wide resection (including the vastus lateralis and vastus intermedius muscles) followed by reconstruction with a megaprosthesis and coverage of the lateral side of the prosthesis with a sartorius muscle flap. Methods: We retrospectively analyzed three patients who underwent reconstruction with a megaprosthesis after wide resection of a primary malignant bone tumor of the distal femur involving the vastus lateralis and vastus intermedius muscles and reconstruction of the soft tissue defect on the lateral side of the prosthesis with a sartorius muscle flap. Results: The average defect size was 6 × 13 cm, the average time required for a sartorius muscle flap was 100 min, and the average implant coverage was 93%. The average postoperative follow-up period was 35 months, during which no postoperative complications such as infection, skin necrosis, or nerve palsy occurred. Discussion: The distally based sartorius muscle flap is easy to elevate in the supine position, has minimal functional loss after harvesting, and has minimal risk of nerve palsy. It can be advocated as the first option for coverage of soft tissue defects lateral to distal femoral replacement.

Introduction: Fractures in ankylosing spine disorders (ASD) are associated with high complication and mortality rates. During the posterior stabilization of these fractures, reduction is often partial, resulting in the persistence of a significant anterior diastasis. Our objective was to evaluate the safety and efficiency of isolated posterior stabilization in elderly ASD patients, without direct reduction of the anterior diastasis, in terms of clinical and radiological outcomes, complications, and mortality. Methods: This retrospective study included 46 patients, mean age 79.3 years, with ASD, who underwent isolated posterior stabilization, open or percutaneous, for thoracolumbar fractures. The average follow-up was 21.7 months, with a minimum follow-up of 6 months. Autonomy (Parker score) and radiological results (lordotic angulation) were analyzed pre-and post-operatively. Results: Autonomy was maintained at the last follow-up, with no significant difference in Parker’s score. The consolidation rate was 94.6%. No implant failure was recorded. Despite the absence of an anterior procedure, lordotic angulation was significantly reduced by 2.6° at 6 months (p = 0.02). The rate of surgical complications following open surgeries was 10.9% (n = 5), of which 6.5% were infections. No surgical complications were reported in percutaneous surgeries. The rate of medical complications was 67.4% (n = 31), with a rate of 88.2% in the open surgery group, compared to 55.2% in the percutaneous surgery group. An open approach was associated with a five-fold higher risk of complications (p = 0.049). Nine patients died during follow-up (19.6%). Conclusions: Isolated posterior stabilization in the treatment of thoracolumbar spine fractures in elderly ASD patients is a safe technique promoting autonomy preservation, and high radiological bony healing with acceptable complication and mortality rates. The persistent anterior gap is partially reduced when the spine is loaded and does not seem to require an anterior procedure, thus decreasing complications. Percutaneous surgery should be the technique of choice to reduce surgical complications.

Background: Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). Methods: This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. Results: POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. Discussion: While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.

Background: Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. Methods: MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. Results: 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6–11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6–200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2–3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0–3.2], implant loosening [RR: 1.0, 95% CI: 0.7–1.5], or revision surgery [RR: 1.3, 95% CI: 1.0–1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: −5.6, 95% CI: −7.6–(−3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6–6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4–4.7], specifically, with prior femoral osteotomy. Conclusion: Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.