Skin crease 'bikini' incision for the direct anterior approach in total hip arthroplasty: a two- to four-year comparative study in 964 patients.

Aims: The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease 'bikini' when the DAA is used for total hip arthroplasty (THA). Patients and Methods: A total of 964 patients (51% female; 59% longitudinal, 41% 'bikini') completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina '4P' scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed. Results: The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the 'bikini' group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the 'bikini' group (p = 0.911). Conclusion: We found that a short oblique 'bikini' skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853-61.

Osteoporosis drug therapy strategies in the setting of disease-modifying agents for autoimmune disease.

The purpose of this systematic review is to evaluate the effects of methotrexate (MTX) and tumor necrosis factor-alpha (TNF-α) inhibitors on bone mineral properties in the clinical literature. A systematic review of the literature identifying relevant case reports, population-based studies, cohort studies, case control studies, and randomized controlled trials in Pubmed and Web of Science databases from inception to December 31, 2011 was conducted. The following keywords were used: "bone turnover," "bone mineral density," "TNF-α inhibitors," "infliximab," "adalimumab," "etanercept," and "MTX." The bibliographies of all retrieved studies were also reviewed to identify additional articles. Based on these results, a rational drug therapy strategy was suggested for treating osteoporosis in patients with inflammatory disease. MTX and TNF-α inhibitors do not appear to have an adverse effect on BMD in patients with inflammatory disease. Their negative effects on BMD and bone turnover in pre-clinical models appear to be outweighed by their anti-disease effects in clinical studies. Treatment with MTX or TNF-α inhibitors has no adverse effect on BMD in patients with inflammatory disease. Future studies will focus on developing optimal drug strategies when combining DMARDs with anti-osteoporotic agents in this patient population.