Does a Commercially Available Augmented Reality-based Portable Hip Navigation System Improve Cup Positioning During THA Compared With the Conventional Technique? A Randomized Controlled Study.

BACKGROUND: Portable hip navigation systems have been developed to combine the accuracy of cup positioning by large console navigation systems with the ease of use and convenience of conventional surgical techniques. Although a novel augmented reality-based portable hip navigation system using a smartphone (AR navigation) has become available recently, no studies, to our knowledge, have compared commercially available AR navigation with the conventional technique. Additionally, no studies, except for those from designer-surgeon series, have demonstrated the results of AR navigation. QUESTIONS/PURPOSES: (1) Does intraoperative use of commercially available AR navigation improve cup positioning compared with the conventional technique? (2) Are operative factors, clinical scores, and postoperative course different between the two groups? METHODS: In this randomized trial, 72 patients undergoing THA were randomly assigned to undergo either commercially available AR navigation or a conventional technique for cup placement. All patients received the same cementless acetabular cups through a posterior approach in the lateral decubitus position. The primary outcome of the present study was cup positioning, including the absolute differences between the intended target and angle achieved, as well as the number of cups inside the Lewinnek safe zone. Our target cup position was 40° abduction and 20° anteversion. Secondary outcomes were operative factors, between-group difference in improvement in the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the postoperative course, including the operative time (between the start of the surgical approach and skin closure), procedure time (between the first incision and skin closure, including the time to insert pins, registration, and transfer and redrape patients in the navigation group), time taken to insert pins and complete registration in the navigation group, intraoperative and postoperative complications, and reoperations. The minimum follow-up period was 6 months, because data regarding the primary outcome-cup positioning-were collected within 1 week after surgery. The between-group difference in improvement in HOOS, which was the secondary outcome, was much lower than the minimum clinically important difference for the HOOS. No patients in either group were lost to follow-up, and there was no crossover (the randomized treatment was performed in all patients, so there was no difference between an intention-to-treat and a per-protocol analysis). RESULTS: The use of the commercially available AR navigation slightly improved cup positioning compared with the conventional technique in terms of the absolute difference between the desired and achieved amounts of cup abduction and anteversion (which we defined as "absolute differences"; median 1° [IQR 0° to 4.0°] versus median 5° [IQR 3.0° to 7.5°], difference of medians 4°; p < 0.001 and median 2° [IQR 1.9° to 3.7°] versus median 5° [IQR 3.2° to 9.7°], difference of medians 2°; p = 0.001). A higher proportion of cups were placed inside the Lewinnek safe zone in the navigation group than in the control group (94% [34 of 36] compared with 64% [23 of 36]; p < 0.001). Median operative times were not different between the two groups (58 minutes [IQR 49 to 72 minutes] versus 57 minutes [IQR 49 to 69 minutes], difference of medians 1 minute; p = 0.99). The median procedure time was longer in the navigation group (95 minutes [IQR 84 to 109 minutes] versus 57 minutes [IQR 49 to 69 minutes], difference of medians 38 minutes; p < 0.001). There were no differences between the two groups in improvement in HOOS (27 ± 17 versus 28 ± 19, mean difference -1 [95% CI -9.5 to 7.4]; p = 0.81). In the navigation group, no complications occurred in the pin sites; however, one anterior dislocation occurred. In the conventional group, one hip underwent reoperation because of a deep infection. CONCLUSION: Although the use of commercially available AR navigation improved cup positioning in THA, the improvement in clinical scores and postoperative complication rates were not different between the two groups, and the overall magnitude of the difference in accuracy was small. Future studies will need to determine whether the improvement in the percentage of hips inside the Lewinnek safe zone results in differences in late dislocation or polyethylene wear, and whether such benefits-if any-justify the added costs and surgical time. Until or unless more compelling evidence in favor of the new system emerges, we recommend against widespread use of the system in clinical practice. LEVEL OF EVIDENCE: Level Ⅱ, therapeutic study.

Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review.

PURPOSE: To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes. RESULTS: Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies. CONCLUSIONS: The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome. LEVEL OF EVIDENCE: Level III, systematic review of level III studies.

Editorial Commentary: Diminished Hip Labral Width May Predict Inferior Outcome After Hip Femoroacetabular Impingement Surgery: Diminutive Labral Width Is a Relative Indication for Labral Reconstruction.

Hip labral "width" should be defined as the distance from the chondrolabral junction to the tip of the labrum in triangular cross-section. "Height" should refer to the distance from the joint surface to the perilabral recess (perpendicular to the width). "Length" is the distance from the anterior end of the labrum, adjacent to the anterior transverse acetabular ligament (TAL), to the posterior end of the labrum, adjacent to the posterior TAL (as may be relevant in reconstructions). Most studies of labral size focus on width, as it is thought to most contribute to the suction seal effect and hip stability. Magnetic resonance imaging most accurately measures labral width. Labral width at the time of surgery should be considered its maximal size; the labrum is reduced in size after repair. Hypoplastic labrums may result in worse outcomes after hip arthroscopy, and hyperplastic labrums may result in higher scores than normoplastic labrums in patients with primary femoroacetabular impingement syndrome. Diminutive labral width is a relative indication for labral reconstruction.

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes: Don't Forget the Young Guns.

It has been said that youth is wasted on the young. This notion does not apply to the value that hip arthroscopy provides in managing hip pathology in adolescents. Multiple studies have shown the efficacy of hip arthroscopy as a treatment modality in the adult population for a multitude of hip pathologies, particularly femoroacetabular impingement syndrome. The implementation of hip arthroscopy in the management of femoroacetabular impingement syndrome in the adolescent population is on the rise. More studies illustrating favorable outcomes following hip arthroscopy in adolescents will serve to reinforce its utility as a treatment option for this population. Early intervention and preservation of hip function are of critical importance in a youthful and active patient population. As a word of caution, acetabular retroversion predisposes these patients to an increased risk of revision surgery.

Acetabular cup placement and offset control in robotic total hip arthroplasty performed through the modified anterolateral approach.

PURPOSE: The modified anterolateral approach (Röttinger) for total hip arthroplasty (THA) offers great advantages over conventional approaches, especially concerning early postoperative symptoms, which are mild and well tolerated by patients. Robotic-assisted implantation might facilitate rapid adoption of the modified anterolateral approach without exposing surgeons to risks encountered during the learning curve. This study posits that the use of robotic assistance in conjunction with the modified anterolateral approach for total hip arthroplasty (THA) can provide a substantial enhancement in the accuracy of cup placement in comparison to manual surgery. METHODS: Thirty-two robotic-assisted THAs met the inclusion criteria and were matched to 32 conventional cases. Acetabular cup inclination, anteversion, limb-length discrepancy, and acetabular offset were assessed using certified planning software by two independent observers using pre- and postoperative anterior-posterior radiographs. Data was analyzed for normal distribution. Chi2 test was used to determine whether implanted acetabular cups that were within Lewinnek's safe zones were influenced by type of implantation. Effect size estimates and statistical power analysis were also performed to appreciate the appropriateness of the chosen sample size. RESULTS: Robotic-assisted implantation was found to significantly improve acetabular cup placement in terms of inclination (p < 0.001) but not anteversion (p = 0.783). Although mean postoperative limb-length discrepancy and mean acetabular offset did not differ between groups, a significantly smaller variance was found in the robotic-assisted group (p < 0.001) and (p = 0.04), respectively. There were no significant differences between the two groups in terms of consistently implanting the acetabular cup within the Lewinnek safe zones p = 0.641 for anteversion and p = 0.230 for inclination, respectively. CONCLUSIONS: Our results show that although robotic-assisted acetabular cup implantation performed through the modified anterolateral approach did not significantly differ from conventional implantation, it did offer increased accuracy in cup positioning, acetabular bone preservation, and limb-length restoration.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

PURPOSE: The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. METHODS: A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. RESULTS: A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. CONCLUSION: The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Ilioinguinal versus modified Stoppa approach for open reduction and internal fixation of displaced acetabular fractures: a systematic review and meta-analysis of 717 patients across ten studies.

BACKGROUND: Acetabulum fracture is one of the most challenging fractures to manage and operate for orthopaedic surgeons; anatomical reduction of fractures and reconstruction of the joint is of utmost importance. These factors in turn are dependent on the appropriate surgical approach used to improve the clinical outcomes and reduce associated complications. Hence, this meta-analysis aims to compare the outcomes of ilioinguinal versus modified Stoppa approach for open reduction and internal fixation (ORIF) of displaced acetabular fractures. METHODS: Medline (PubMed), Embase, Scopus, and Cochrane Library databases were searched from their inception to 10th of June 2021 for both randomized clinical trials (RCTs) and or non-randomized studies comparing the outcomes of ilioinguinal approach and modified Stoppa approach for the ORIF of acetabular fractures. The estimates of treatment effects were described by mean difference (MD) for continuous variables and odds ratio (OR) for dichotomous variables with corresponding 95% confidence (95% CI) intervals. The risk of bias was assessed by MINORS tool for the non-randomized, and the Cochrane Collaboration's risk of bias tool for RCTs. RESULT: A total of ten studies (717 patients), three RCTs and seven retrospective studies, were included. Modified Stoppa approach showed shorter mean duration of surgery (MD 47.13, 95% CI: 27.30-66.96), lesser number of overall complications (OR 2.14, 95% CI: 1.46-3.13), less intraoperative blood loss (MD 259.65, 95% CI: 152.66-366.64), and lower rates of infection (OR 2.17, 95% CI: 1.14-4.15). However, ilioinguinal approach showed a better quality of fracture reduction (OR 0.59, 95% CI: 0.42-0.82). Results were equivocal in terms of vascular injuries (OR 1.88 (95% CI: 0.86-4.09), nerve injuries (OR 1.77, 95% CI: 0.99-3.17), heterotopic ossification (OR1.74, 95% CI: 0.63-4.82), and clinical outcome (OR 0.81, 95% CI: 0.45-1.47) between the two groups. CONCLUSION: Modified Stoppa approach carries a lesser duration of surgery, lesser intraoperative blood loss, fewer overall complications, and lesser postoperative infection rates compared to ilioinguinal approach. Although a better anatomical reduction is achieved by ilioinguinal approach, however, this does not translate into better clinic functional outcomes which remain comparable between the two approaches. So overall, modified Stoppa approach seems a better alternative for managing these fractures.

Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review.

Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms ("Acetabular" OR "Acetabulum") AND ("Heterotopic Ossification" OR "HO" OR "Ectopic Ossification"). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217-224, 2023).

Editorial Commentary: Hip Central Acetabular Osteophyte Treatment Improves Outcome: Flip Your Arthroscope 90° and Look Down!

Three goals are at the top of our minds when achieving optimal outcomes for the arthroscopic treatment of femoroacetabular impingement syndrome in the primary setting: (1) accurate bony correction, (2) labral function restoration-typically with labral repair-and (3) comprehensive capsular management-which involves capsular preservation and closure. Notwithstanding, additional intra-articular concomitant conditions require our attention as well. Central acetabular impingement is characterized by the presence of central acetabular osteophytes at the cotyloid fossa. It has been proposed that central acetabular osteophytes lead to lateralization of the femoral head with relative femoroacetabular incongruency that increases contact force and mechanical cartilage abrasion.

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement in Patients With Borderline Dysplasia Does Not Result in Inferior Outcomes Compared With Outcomes in Patients Without Dysplasia: Do Not Fear.

The treatment of adult borderline hip dysplasia remains challenging and continues to be a subject of controversy. The preferred treatment for hip instability and acetabular undercoverage is periacetabular osteotomy. However, patients with painful hips and associated femoroacetebular impingement, microinstability, or no instability may benefit from arthroscopic surgery. Short-term studies have reported favorable clinical outcomes. Traditionally, the lateral center-edge angle was used to determine hip dysplasia. More recently the femoro-epiphyseal acetabular roof (FEAR) index was introduced as a measure for borderline dysplasia. In general, a FEAR index of less than 5° indicates hip instability. When using a FEAR index of more than 2° as a cut-off for hip instability and borderline dysplasia, arthroscopic hip surgery can achieve very similar clinical outcomes to patients with a FEAR index of less than 2°. However low and unequal sample sizes have potentially resulted in both type I and II errors, reducing internal study validity. Although this may be a step in the right direction, further high-quality studies are required to understand patients' characteristics on diagnosis, prognosis, outcomes of surgical interventions, and long-term disease progression for adult borderline hip dysplasia.

Fluoroscopic Percutaneous Fixation of Periacetabular Metastatic Cancer: The Tripod Technique.

There are an increasing number of patients who present with metastatic bone disease as the survival of patients with cancer improves in recent decades. The pelvis is the second most common site for skeletal metastases. Metastatic lesions in the pelvis can be largely divided into periacetabular lesions (Enneking zone II) and non-periacetabular lesions (zones I, III, and IV). Traditionally, patients with a symptomatic zone II lesion are treated with a cemented total hip arthroplasty (THA) using variations on the traditional Harrington method. These open surgeries are accompanied by many inherent risks. Both a prolonged recovery and wide range of potential complications may delay or interrupt the adjuvant radiation and systemic therapy. It was observed that the articular surface of the hip joint was often intact and that the femoral side was frequently not involved in these patients. A novel minimally invasive technique for hip joint preservation has recently been developed. Three large-bore cannulated screws are placed percutaneously under fluoroscopy in a tripod configuration to reinforce the mechanical axis of the acetabulum. Increased stability improves pain control and permits immediate weight bearing. When the disease progresses, this construct can be easily converted to a cemented THA using the tripod screws as rebar to support an acetabular cup, as part of a staged Harrington procedure. This approach is technically demanding. A detailed guide for the tripod technique should encompass indications, preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, modifications, postoperative care, and subsequent conversion to a cemented THA, if needed.

Clinical efficacy and its influencing factors of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches.

BACKGROUND: The objective of this study was to evaluate the outcomes of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches and its influencing factors. METHODS: Between January 2009 and June 2018, a total of 21 patients with T-shaped acetabular fractures involving posterior wall were treated with combined approaches. The combined approaches were a combination of the Kocher-Langenbeck (KL) approach and the anterior approach (Stoppa or Ilioinguinal). The acetabular fractures in this study were divided into two groups respectively according to surgical approach and surgical timing: KL + Ilioinguinal (IL) approaches and KL + Stoppa approaches, early surgery and late surgery. RESULTS: 13 cases were treated within 14 days of injury. 15 cases were treated using the KL + Stoppa approaches and remaining 6 cases were treated using the KL + IL approaches. Anatomical and imperfect reduction were achieved in 12 cases (57.1%) with excellent to good clinical outcome in 42.9% of cases. Early surgery had a statistically significant improvement over late surgery in terms of quality of reduction and clinical outcomes. In the early surgery, the incidence of preoperative chest and abdomen injuries and postoperative deep vein thrombosis was significantly lower than that of the late surgery. There was no statistical difference between the KL + IL approaches and KL + Stoppa approaches in the demographics, preoperative associated injuries, quality of reduction, clinical outcomes and postoperative complications. CONCLUSIONS: The results of this study indicate that T-shaped associated with posterior wall acetabular fractures are difficult to treat surgically. Early surgery can improve the quality of fracture reduction, promote the recovery of hip function, and decrease the incidence of postoperative deep vein thrombosis. The main factor that affects surgical timing is the presence of preoperative chest and abdominal injuries. Compared with the KL + IL approaches, the KL combined with Stoppa approach can not significantly improve the clinical outcomes of such acetabular fractures.

The lateral joint space width is essential for the outcome after arthroscopically assisted mini-open arthrotomy for treatment of a femoroacetabular impingement: an analysis of prognostic factors for the success of this hip-preserving technique.

PURPOSE: The purpose of this study was to analyze predicting factors for a conversion to a total hip replacement (THR) after mini-open arthrotomy for treatment of femoroacetabular impingement (FAI). METHODS: Between 2011 and 2016, we identified 32 patients, who were treated for FAI with a mini-open arthrotomy and received after mean time of 2.1 ± 1.4 years a THR. These patients were compared to 47 cases who did not receive a THR (mean follow-up: 4.3 ± 0.7 years) to explore pre- and intra-operative factors associated with a conversion to THR. The results were presented in separated Kaplan-Meier curves with log rank test for significance and hazard ratios. RESULTS: A lateral joint space width of > 4 mm showed a higher THR-free survival rate compared to < 4 mm (p = 0.001); analogously one-sided (acetabular/femoral) 3-4° cartilage damage had a comparable THR-free survival rate than 1-2° kissing lesions (p = 0.001). Furthermore, an intact labrum without treatment and good cartilage status, a refixed labrum after rim resection in case of a pincer type FAI, or a refixed teared labrum were associated with a longer THR-free time than an untreated labrum accompanied by a poor cartilage status or an ossified labrum (p = 0.002). The strongest independent factor for a conversion to THR was femoral cartilage damage grade 1 and higher (p = 0.046). However, the rate of available patients was 53.0%. CONCLUSION: The success of a joint-preserving mini-open arthrotomy seems to be dependent on the status of the radiological joint space width and the intra-operative cartilage status of the lateral edge.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients.

INTRODUCTION: Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA. MATERIALS AND METHODS: Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures. RESULTS: The mean age was 80.5 years (range 65-98 years). The average time from injury to surgery was 8.5 days (range 1-28). Mean time of surgery was 167 min (range 100-303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification. CONCLUSIONS: The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

[The meaning of cartilage therapy in the treatment of FAIS : Is a specific cartilage therapy necessary or is deformity correction sufficient?] / Bedeutung der Knorpeltherapie in der Behandlung des FAIS : Ist eine spezifische Knorpeltherapie erforderlich oder reicht die Deformitätenkorrektur?

Femoroacetabular impingement syndrome (FAIS) surgery aims to restore the natural anatomical relationships between bones and the soft tissues comprising the hip joint. Most cartilage repair methods for the hip are based on basic science and strategies that were developed for the knee. Currently, there is a lack of information in the literature regarding systematic reviews on evidence-based options in treating cartilage injuries of the hip joint. The aim of this article is to assess treatment options and their related outcomes for chondral injuries in the hip based on the available evidence whilst highlighting new and innovative techniques.

[Surgical treatment of femoroacetabular impingement syndrome : Arthroscopy-mini-open-surgical hip dislocation]. / Auswahl des Operationsverfahrens beim Femoroazetabulären Impingement-Syndrom : Arthroskopie ­ "mini-open" ­ chirurgische Hüftluxation.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is one of the most common prearthritic hip deformities. Since FAIS is a mechanical pathology, surgical correction of the underlying deformity is the sole causal treatment. If surgery is indicated, a surgical technique that results in complete deformity correction with least morbidity should be selected. ARTHROSCOPY: Due to advancements in techniques and instruments, most pathologies in FAIS can nowadays be addressed arthroscopically. Hip arthroscopy can be successfully performed if the locations of the pathologies are anterior and lateral. MINI-OPEN APPROACH: In special cases and indications-like periarticular pathologies, pathologies of the hip capsule and large labral reconstructions and transplantations, a combination of arthroscopy with a mini-open approach is advantageous. Furthermore, the learning curve of hip arthroscopy can be improved with an additional open approach. SURGICAL HIP DISLOCATION: Global and circumferential pathologies still have to be addressed in surgical hip dislocation to avoid residual deformities. Finally, extraarticular osteotomies have to be considered in cases with significant rotational deformities.

Acetabulum fractures in elderly patients: A review.

Fractures of the acetabulum in elderly patients were often caused by low energy trauma. Fractures involving anterior column are more common and often associated with impaction and comminution. Osteoporosis further complicates the management. Percutaneous fracture fixation has low morbidity but it is a technically demanding procedure. Open reduction and fracture fixation is done with or without simultaneous total hip replacement. Delayed total hip replacement is considered in posttraumatic arthritis patients. Patients with minimal displaced fractures, associated both-column fractures with secondary congruence of joint and patients who are medically unfit for surgery can be managed non-operatively. Whatever be the method of management, these elderly patients should be mobilised as early as possible.

Management of Complex Acetabular Fractures by Using 3D Printed Models.

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient's individual anatomy after surgery.

Acetabular labral reconstruction with medial meniscal allograft: preliminary results of a new surgical technique.

PURPOSE: Reconstruction of the acetabular labrum during femoroacetabular impingement (FAI) surgery is accepted when the labrum is deficient and irreparable. Here we describe a novel technique using fresh-frozen medial meniscal allograft for labral reconstruction during surgical hip dislocation for correction of pincer FAI due to acetabular overcoverage. METHODS: The results from seven hips (six patients) that underwent this procedure with 1 year minimum follow-up, and radiographs are presented. RESULTS: Six of the seven hips had improvements in pain, hip flexion, hip abduction, and Merle d'Aubigné-Postel scores. Only one patient with pre-existing osteoarthritis underwent reoperation with conversion to total hip arthroplasty. All digastric trochanteric osteotomies healed, and there were no cases of femoral head osteonecrosis or progression of Tönnis grades. CONCLUSIONS: The medial meniscus is a morphologically and clinically suitable option for labral reconstruction and effectively restores the hip fluid seal.

Internal fixation of anterior acetabular fractures with a limited pararectus approach and the anatomical plates: preliminary results.

BACKGROUND: The surgical treatment of acetabular fracture has adverse outcomes and high risk, and minimally invasive method is a good way to reduce complications and improve hip joint function. This study is to investigate the treatment of certain acetabular fractures primarily involving the anterior column and quadrilateral plate using a limited pararectus approach and the anatomical plates. METHODS: A consecutive cohort of 17 patients with anterior displaced acetabular fractures were managed operatively with a limited approach and the anatomical plates. Ten patients had anterior column fractures, 1 patient had anterior wall fracture, 4 patients had transverse fractures and 2 patients had anterior column with posterior hemi-transverse fractures. The inferior half of the pararectus approach was adopted to open the medial window and to access the anterior column and the quadrilateral plate. The anatomical plates were used for internal fixation. Residual displacements were assessed on the postoperative CT scans using a standardized digital method. The surgical details, hip functional outcomes, and complications were noted. RESULTS: All of the patients were operated using the limited pararectus approach and the anatomical plates successfully. The mean operative time and blood loss were 90.9 min and 334.1 ml, respectively. The average postoperative residual gap and step displacement on CT were 2.9 mm and 0.7 mm, respectively. The radiological outcome was estimated according to the Matta score, ten of the cases were graded anatomical, six were graded imperfect, and one was graded poor. Follow up averaged 15 months. Functional outcomes were excellent for nine, good for six, and fair for two. It was noted that one case of peritoneal injury was repaired intraoperatively. CONCLUSIONS: The limited pararectus approach with the advantages of less trauma, direct exposure to the anterior column and quadrilateral plate. The anatomical plates can fit with the surface of the acetabulum, which saves the time of remodeling plates during operation and facilitate fracture reduction. The combination approach can be a good choice for limited surgery of displaced anterior acetabular fractures especially involving the quadrilateral plate.