Serum biomarkers for the assessment of muscle damage in various surgical approaches in primary total hip arthroplasty: a systematic review of comparative studies.

PURPOSE: Using serum biomarkers, this systematic review assessed soft tissue injury following different total hip arthroplasty surgical approaches. The purposes were to determine if there is any advantage between the standard and minimal invasive approaches, and to compare tissue damage of the respective surgical approaches using biomarkers such as creatine kinase, myoglobin, c-reactive protein, erythrocyte sedimentation rate, skeletal troponin and interleukins. METHOD: A search in Pubmed/MEDLINE, Scopus and Web of Science databases was conducted in October 2021 with the use of PRISMA guidelines. Search items were ("biomarkers" OR "markers" OR "tissue damage" OR "muscle damage") AND "approach" AND ("total hip arthroplasty" OR "total hip replacement"). Inclusion criteria were prospective, randomized, controlled trials or prospective, comparative studies, comparing serum markers for muscle damage in two or more surgical approaches for primary total hip arthroplasty. Exclusion criteria were study protocols, case reports, systematic reviews, meta-analyses, studies in non-English language or without available full text, and studies not recording biomarkers of muscle damage. RESULTS: Initial search revealed 508 studies; after subtraction of duplicates, and exclusion criteria, 31 studies remained for analysis. No advantage between different approaches was found when evaluating biomarkers, and no specific biomarkers had a distinct role in tissue damage in total hip arthroplasty. Anterior and minimally invasive approaches were associated with lower values of soft tissue (creatine kinase) and inflammation (c-reactive protein) biomarkers compared to the standard approaches. CONCLUSION: Measurement of serum biomarkers after primary total hip arthroplasty for the estimation of tissue damage has unclear or little clinical value. TRIAL REGISTRATION: PROSPERO Registration: CRD42022303959.

Intra-abdominal and intra-pelvic complications following operations around the hip: causes and management-a review of the literature.

Although successful and well-established procedures, hip operations whether elective or trauma are coupled with a variety of complications. Among the most uncommon complications are injuries to intra-abdominal or intra-pelvic organs which could prove potentially life-threatening. While there are various reports of such injuries in the literature, we aimed to perform a systematic review in order to examine the causes and relationships between intra-abdominal and intra-pelvic complications and the mechanism of injury, the pattern of presentation, identification, the course of management and outcomes. We identified 69 reports describing a total of 84 complications in intra-pelvic and intra-abdominal contents in 75 patients. These involved six major categories, including the intestinal tract, the urinary tract, the genital tract, the vascular system, the viscera and peripheral nerves. The most commonly injured system was the urinary (33.33%), followed by the vascular (29.76%) and the intestinal (22.62%). Among these systems, the most prevalent complications involved injury to the urinary bladder (32.14%), the large intestine (68.42%) and the external iliac artery (44%). The majority of recorded complications were postoperative with 71 incidents in 63 cases (84.52%). In intra-operative complications the most prevalent injury was due to hardware penetration (53.85%), while in postoperative it was due to hardware migration (92.06%). The management of injuries varied widely, with the most common approach being open exploration and direct repair (77.33%). The reported management outcomes included death (8%) and Girdlestone resection (2.67%), while the majority of the patients healed uneventfully (82.67%) owing mostly to immediate intervention. Despite being rare, such complications may still occur in a variety of settings and may subsequently lead to potential life-threatening situations. Thus, in order to avoid catastrophic outcomes we emphasize the need for prompt identification, immediate intervention and a multidisciplinary approach when necessary.

Survivorship of a Porous Tantalum Monoblock Acetabular Component in Primary Hip Arthroplasty With a Mean Follow-Up of 18 Years.

BACKGROUND: The use of porous tantalum for the acetabular component in primary total hip arthroplasty (THA) has demonstrated excellent short-term and midterm results. However, long-term data are scarce. The purpose of this prospective study is to report the long-term clinical and radiologic outcome following use of an uncemented porous tantalum acetabular component in primary THA with a minimum follow-up of 17.5 years, in a previously studied cohort of patients. METHODS: We prospectively followed 128 consecutive primary THAs in 140 patients, between November 1997 and June 1999. A press-fit porous tantalum monoblock acetabular component was used in all cases. All patients were followed clinically and radiographically for a mean of 18.1 years (range, 17.5-19 years). RESULTS: Mean age of patients at the time of operation was 60.4 years. Harris hip score, Oxford hip score, and range of motion were dramatically improved in all cases (P < .001). At last follow-up, all cups were radiographically stable with no evidence of migration, gross polyethylene wear, progressive radiolucencies, osteolytic lesions, or acetabular fractures. The survivorship with reoperation for any reason as end point was 92.8% and the survivorship for aseptic loosening as an end point was 100%. CONCLUSION: The porous tantalum monoblock cup in primary THA demonstrated excellent clinical and radiographic outcomes with no failures because of aseptic loosening at a mean follow-up of 18.1 years.

Results from the surgical resection of severe heterotopic ossification of the hip: a case series of 26 patients.

INTRODUCTION: Surgical resection of heterotopic ossification (HO) around the hip joint is often challenging. The aim of this study is to evaluate the clinical and radiological outcomes following surgical resection of Brooker's type III and IV HO of the hip. METHODS: We retrospectively reviewed clinical and radiological data, between November 2006 and January 2013, of all patients who underwent surgical resection of severe HO of the hip. Brooker's grading, range of motion and the Harris Hip Score before and after surgery were recorded in all cases. The combined radiation (700 cGy preoperatively) and indomethacin regimen was used to prevent heterotopic ossification recurrence. RESULTS: Twenty-six patients (22 males and 4 females) were included in our study. Mean patient age was 47.38 years (range 24-72). The HO was graded as Brooker grade III in 3 patients (11.5%) and Brooker grade IV in 23 patients (88.5%). Mean time interval between HO development and resection was 40.8 months (range 13-156 months). All patients had CT scans prior to surgery. Mean follow-up was 31.4 months (range 24-40 months). There was no severe HO recurrence. Complications included one intraoperative injury of a femoral artery branch, one intraoperative femoral neck fracture treated with intramedullary nailing, one sciatic nerve injury and one superficial infection treated conservatively. CONCLUSIONS: Surgical resection of severe HO of the hip along with preoperative radiation and indomethacin provides excellent results; however, the complication rate is relatively high. Careful evaluation of the preoperative CT scan and wide exposure are required in order to identify all the involved neurovascular structures.

Pain management after total hip arthroplasty: comparative study of analgesic efficacy and tolerability between oral tramadol/dexketoprofen and injectable paracetamol + tramadol.

BACKGROUND: Multimodal analgesia for total hip arthroplasty (THA) is increasingly employed to reduce early postoperative pain and promote fast patient discharge. The aim of this study was to compare the efficacy and tolerability of tramadol/dexketoprofen (TRAM/DKP, Group A) versus paracetamol + tramadol (PARA+TRAM, Group B) in patients undergoing THA using minimally invasive direct anterior approach (DAA). METHODS: A single-centre, randomised, single-blind, parallel, interventional study conducted in 323 patients undergoing primary THA with DAA was performed. Group A consisted of 188 patients and Group B of 135. The primary endpoints were the change from baseline (measured 2 hours postoperatively) in pain intensity (PI) during the treatment period (48 hours), assessed by visual analogue scale (VAS) at pre-specified postoperative time-points (2, 8, 24, 48 hours) and the total rescue medication (RM) use during the first 24 hours postoperatively. RESULTS: As early as 2 hours after baseline, Group A showed a greater PI reduction from baseline compared to Group B (-26.24% vs. -6.87%; p < 0.001). A lower mean PI (VAS) score was consistently found over the entire observation period following treatment with TRAM/DKP than with PARA+TRAM as well as more than 2-fold higher proportion of responders at the end of treatment period. More patients in Group B required RM in comparison to those in Group A (15.6% vs. 3.7%, p < 0.001). Both treatments were well tolerated. CONCLUSIONS: After THA, oral TRAM/DKP provides faster and greater pain relief when compared to intravenous PARA+TRAM with limited consumption of RM and favourable tolerability profile. Our study expands the use of TRAM/DKP in the setting of major orthopaedic surgeries. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT04178109).

The Association of MMP-2, MMP-9, and MMP-13 Gene Polymorphisms With Knee Osteoarthritis in the Greek Population.

Introduction Primary knee osteoarthritis (OA) is a multifactorial degenerative joint disorder characterized by articular cartilage degradation. Matrix metalloproteinases (MMPs) have been reported to play a vital role in OA pathogenesis, significantly contributing to extracellular matrix (ECM) catabolism. The purpose of this study is to investigate the association of MMP-2 -1575G/A (rs243866), MMP-9 836A/G (rs17576), and MMP-13 -77A/G (rs2252070) gene polymorphisms with knee OA in the Greek population. Methods One hundred patients (24% males, mean age: 68.3 years) with primary knee OA were included in the study along with 100 controls (47% males, mean age: 65.2 years). Genotypes were identified through polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) technique. Allelic and genotypic frequencies were compared between patients and controls. Results The MMP-13 -77A/G polymorphism was significantly associated with knee OA in the crude analysis (P = 0.008). After binary logistic regression analysis, the dominant model of the MMP-13-77A/G (AG + GG versus AA) was found to be associated with increased risk for knee OA (odds ratio (OR) = 2.290, 95% confidence interval (95%CI) = 1.059-4.949, P= 0.035). Compared to the A allele, the G allele in the MMP-13rs2252070 locus was a predictive factor for knee OA (OR = 2.351, 95%CI = 1.134-4.874, P= 0.022). No significant associations were detected for the MMP-2 -1575G/A and MMP-9 836A/G polymorphisms (P > 0.05). Conclusions The present study shows that the MMP-2 -1575G/A and MMP-9 836A/G polymorphisms are not significantly associated with primary knee OA in the Greek population. The MMP-13 -77A/G was found to be a significant risk factor for knee OA in the Greek population. Additional research is needed to verify this association in larger and different populations, in different joints, to elucidate the role of this single nucleotide polymorphism (SNP) in OA pathogenesis.

Multiplex cytokine analysis for the identification of novel potential synovial fluid biomarkers for periprosthetic joint infections.

INTRODUCTION: Periprosthetic joint infections (PJIs) are a devastating complication of total hip (THA) and knee (TKA) arthroplasty. The use of novel techniques like multiplex cytokine analysis could contribute immensely to the identification of potential novel biomarkers. PATIENTS AND METHODS: This is a single-centre study of patients that were treated with revision TKA, THA or hemiarthroplasty. Serum's white blood cells (WBCs), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and synovial fluid's WBCs, percentage of polymorphonuclear neutrophils (%PMNs) and CRP were measured. Proteomic analysis targeting the secreted cytokines in synovial fluid was conducted using a 73-plex assay panel. The results were statistically compared between the septic and aseptic cases and ROC analysis to establish the area under the curve (AUC), sensitivity and specificity of each biomarker. RESULTS: The study included 30 patients (18 revision THA cases; 3 conversion of hemiarthroplasty to THA and 9 revision TKA cases); 14 cases were considered infected, 1 likely infected and 15 not infected. The results showed statistically significant differences (p < 0.05) between infected and not infected cases in serum's ESR, CRP and synovial fluid's%PMNs, growth-regulated oncogene alpha (GROA), interleukin-8, interleukin-5, S100-A8/calprotectin and resistin (RETN) with AUCs of 0.75, 0.72, 0.95, 0.75, 0.72, 0.95, 0.83, 0.73, 0.75, 0.81 and 0.76 respectively. CONCLUSIONS: In the present study, serum ESR and CRP as well as synovial %PMNs, GROA, IL-8, IL-5, calprotectin and RETN protein levels were identified as potential biomarkers. Further studies are needed to further investigate their diagnostic utility and optimal cut-off values.

Intraoperative calprotectin lateral flow immunoassay can assist decision-making between one- and two-stage revision total hip arthroplasty for patients with suspected periprosthetic joint infection.

Aims: Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI. Methods: The study included 48 THAs in 48 patients with a clinical suspicion of PJI, but who did not meet European Bone and Joint Infection Society (EBJIS) PJI criteria preoperatively, out of 105 patients undergoing revision THA at our institution for possible PJI between November 2020 and December 2022. Intraoperatively, synovial fluid calprotectin was measured with LFI. Cases with calprotectin levels ≥ 50 mg/l were considered infected and treated with two-stage revision THA; in negative cases, one-stage revision was performed. At least five tissue cultures were obtained; the implants removed were sent for sonication. Results: Calprotectin was positive (≥ 50 mg/l) in 27 cases; out of these, 25 had positive tissue cultures and/or sonication. Calprotectin was negative in 21 cases. There was one false negative case, which had positive tissue cultures. Calprotectin showed an area under the curve of 0.917, sensitivity of 96.2%, specificity of 90.9%, positive predictive value of 92.6%, negative predictive value of 95.2%, positive likelihood ratio of 10.6, and negative likelihood ratio of 0.04. Overall, 45/48 patients were correctly diagnosed and treated by our algorithm, which included intraoperative calprotectin measurement. This yielded a 93.8% concordance with postoperatively assessed EBJIS criteria. Conclusion: Calprotectin can be a valuable tool in facilitating the intraoperative decision-making process for cases in which chronic PJI is suspected and diagnosis cannot be established preoperatively.

Which patients are at risk for kidney dysfunction after hip fracture surgery?

BACKGROUND: Kidney dysfunction (KD) after hip fracture surgery is a major complication. However, the incidence and risk factors of KD in this population are unclear. QUESTIONS/PURPOSES: We therefore (1) determined the incidence of KD in a large cohort of fracture patients, (2) identified preoperative risk factors predisposing to KD, and (3) determined the effect of KD on length of stay and subsequent function. METHODS: Between April 2011 and June 2012, 450 patients (263 women) with a mean age of 73 years (range, 67-96 years) underwent surgery for hip fracture in our institution. We calculated incidence and retrospectively reviewed suspected predisposing risk factors. We report followup at 6 months. RESULTS: The overall incidence of KD was 11% (n = 52). Forty-five patients (86%) developed acute KD and seven patients developed acute-on-chronic KD. Three of the 52 patients died during the followup time. Thirty-eight of the 52 patients (73%) regained their prior kidney function after treatment. An increased risk of KD was found in those with diabetes, shock during or after surgery, age, and preexisting KD. Mean length of stay was higher for patients with KD compared to those without: 9.6 versus 7.4, respectively. At 6 months, 39 of the 49 surviving patients (80%) were fully weightbearing. CONCLUSIONS: Many patients at risk for postoperative KD can be identified and treated. Most patients recover from their KD and the majority return to full weightbearing.

Acetabular erosion after bipolar hip hemiarthroplasty for femoral neck fracture in elderly patients: a retrospective study.

BACKGROUND: The choice between total hip arthroplasty (THA) and hemiarthroplasty (HA) to treat displaced femoral neck fractures, particularly among the elderly, is still controversial. Acetabular erosion consists of a late multifactorial process that may happen after hip HA resulting in significant postoperative burden. This study aims to investigate the impact of acetabular erosion progress after hip HA in patients over 70 years old. MATERIALS AND METHODS: This is a 5-year (2013-2018) retrospective study including consecutive series of patients >70 years who were treated with bipolar hip HA for femoral neck fractures. Patients were categorised into 3 groups for analysis (A = 70-75 years, B = 75-80 years, C = >80 years). The study enrolled a total number of 813 patients who met the inclusion criteria. We assessed acetabular erosion through radiological examinations and measured functional deterioration using the modified Harris Hip Score (mHHS) at 6 and 12 months follow-up. Our comprehensive investigation extended over a maximum period of 5 years. The correlation of patients' characteristics and HA features on erosion progress was assessed. RESULTS: There were no significant differences in sex distribution, injury side, BMI, ASA score, bipolar head diameter, mHHS and leg-length discrepancy among the groups (p > 0.05). During the follow-up period, acetabular erosion with consequential conversion to THA was observed in 6.13%, 4.22% and 1.96% for Groups A, B and C respectively (p = 0.009). A statistically significant difference of acetabular erosion was observed in Group A compared to patients of Group C. CONCLUSIONS: Age constitutes a significant factor of acetabular wear after HA in the elderly. The higher rate of acetabular wear in patients <75 years suggests that THA is a more viable option, as HA is for patients >80 years old.

Analysis of kidney dysfunction in orthopaedic patients.

BACKGROUND: This retrospective study was undertaken to determine the incidence of kidney dysfunction (KD) and to identify potential risk factors contributing to development of KD in orthopaedic population following an elective or emergency surgery. METHODS: A total of 1025 patients were admitted in our institution over a period of one year with various indications. Eight hundred and ninety-three patients (87.1%) had a surgical procedure. There were 42 (52.5%) male and 38 (47.5%) female with a mean age of 72 years (range: 47 to 87 years). We evaluated the following potential risk factors: age, comorbidities, shock, hypotension, heart failure, medications (antibiotics, NSAIDs, opiates), rhabdomyolysis, imaging contrast agents and pre-existing KD. RESULTS: The overall incidence of KD was 8.9%. Sixty-eight patients developed acute renal injury (AKI) and 12 patients developed acute on chronic kidney disease (CKD). In sixty-six (82.5%) patients renal function was reversed to initial preoperative status. Perioperative dehydration (p = 0.002), history of diabetes mellitus (p = 0.003), pre-existing KD (p = 0.004), perioperative shock (p = 0.021) and administration of non-steroid anti-inflammatory drugs (NSAIDs) (p = 0.028) or nephrotoxic antibiotics (p = 0.037) were statistically significantly correlated with the development of postoperative KD and failure to gain the preoperative renal function. CONCLUSION: We conclude that every patient with risk factor for postoperative KD should be under closed evaluation and monitoring.

Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures?

BACKGROUND: Proximal femoral nail antirotation devices (PFNAs) are considered biomechanically superior to dynamic hip screws for treating unstable peritrochanteric fractures and reportedly have a lower complication rate. The PFNA II was introduced to eliminate lateral cortex impingement encountered with the PFNA. However, it is unclear whether the new design in fact avoids lateral cortex impingement without compromising stability of fixation and fracture healing. QUESTIONS/PURPOSES: We therefore asked whether the PFNA II: (1) eliminates the lateral cortex impingement and fracture displacement experienced with PFNA; and (2) provides stable fracture fixation with a low major complication rate for unstable fractures in European patients. METHODS: We retrospectively reviewed 108 patients with an unstable peritrochanteric fracture, 58 treated with PFNA and 50 with PFNA II. We compared nail positioning, major and minor complication rates, operative and fluoroscopy time, blood transfused, time to mobilization, hospital stay, fracture union, and Harris hip score. The minimum followup was 12 months (mean, 13 months; range, 12-18 months). RESULTS: In the PFNA II group we encountered no impingement on the lateral cortex and no patients with lateral fragment or loss of reduction at insertion, whereas with the PFNA group, we had 10 and five cases, respectively. Fracture union occurred in all patients treated with PFNA II without mechanical failures. PFNA II cases were associated with a slightly shorter surgical time than PFNA cases (23 minutes versus 27 minutes, respectively). CONCLUSION: PFNA II avoided lateral cortex impingement experienced with PFNA, providing fast and stable fixation of the unstable peritrochanteric fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients.

AIMS: There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. METHODS: Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m2 who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. RESULTS: No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). CONCLUSION: Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4-11.

Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach.

INTRODUCTION: An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. METHODS: A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. RESULTS: After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. CONCLUSIONS: In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.

Hemiarthroplasty of the hip using the direct anterior approach.

OBJECTIVE: Minimally invasive approach in total hip arthroplasty for the treatment of femoral neck fractures with a hemiarthroplasty. INDICATIONS: Femoral neck fractures of patients without hip osteoarthritis where the acetabulum is still intact. CONTRAINDICATIONS: Lesions and infections of the skin in the approach area; hip osteoarthritis; surgeon's lack of experience with the technique. SURGICAL TECHNIQUE: The direct anterior approach (DAA) uses the Smith-Peterson interval between the tensor fasciae latae (TFL) and the rectus and sartorius muscle. After coagulation of the ascending branches of the femoral circumflex vessels, the capsule is opened. The remaining parts of the femoral neck are removed and osteotomized if necessary. The femoral head is removed with a cork screw. Then the shaft is supported by 2 sharp retractors at the greater trochanter from cranial, and the leg is externally rotated, hyperextended, and adducted. A TFL release can be performed which we also recommend. The femoral canal is opened step by step and extended with rasps which are introduced with the double curved broach handle. Cement and the final implant are introduced and after the trial reduction also the final head. The hip is reduced, the capsule adapted and the wound closed. POSTOPERATIVE MANAGEMENT: For this approach, there are no approach specific recommendations. Postoperative treatment depends on whether the approach was extended with muscle releases and on the type of reconstruction performed. If the approach was limited to the minimally invasive direct anterior portal, quicker rehabilitation can be expected due to the reduced muscle damage. We prefer mobilization with full weight bearing as tolerated on the next day.

Direct anterior approach total hip arthroplasty with an orthopedic traction table.

OBJECTIVE: Direct anterior approach total hip arthroplasty (DAA THA) has gained significant popularity in the last decade as it is a muscle-sparing procedure. Modern techniques for DAA THA utilize both a standard operating table and an orthopedic traction table. As the use of an orthopedic traction table shows technical ease and predictability, this article will focus on the use of the orthopedic table or table extension to facilitate DAA THA. INDICATIONS: Primary or secondary arthritis requiring THA; revision surgery-both acetabular and femoral. CONTRAINDICATIONS: Posterior wall hardware requiring removal; posterior mass (tumor) to be removed at surgery: large, overhanging pannus; need for gluteal tendon reconstruction; anterior skin envelope not conducive to DAA. SURGICAL TECHNIQUE: The incision is made over the tensor fascia latae. Capsulotomy is performed exposing the hip joint. After osteotomy of the femoral neck, traction is placed on the leg utilizing the orthopedic table and the head is removed. The acetabular cup is inserted. Traction, flexion, and internal reduction are used simultaneously while directing the femoral head into the acetabulum. RESULTS: In a meta-analysis, operative time (100 vs. 71 min), blood loss (531 vs. 382 ml), and intraoperative fracture rate (1.7 vs. 1.3%) were increased in the traction table cohort. All other complications and outcome measurements were the same. Traction-table related complications such as pudendal nerve palsy and ankle fractures were not found. An assessment of the senior author's initial 855 DAA THAs (2008-2014) showed a mean operative time of 65 min with a mean blood loss of 238 ml. Operative times decreased to average 56 min. Intraoperative fracture rate was 0.8%. Infection rate was 2.1%. Finally, 1.5% femoral implants did not osseointegrate and required revision after an average of 3.0 years.

Modified Harris Hip Score as patient-reported outcome measure in osteoarthritic patients: psychometric properties of the Greek version.

INTRODUCTION: This study explored the psychometric properties of the modified Harris Hip Score-Greek version (mHHS-Gr) as a patient-reported outcome (PRO) measure in osteoarthritic hip patients. METHODS: Internal consistency, test-retest reliability and reproducibility were evaluated in 90 patients aged >55 years. Construct validity was tested against Greek versions of the Lower Extremity Functional Scale (LEFS-Greek) and WOMAC Index (WOMAC-Gr), and the Timed Up and Go (TUG) and 9-stairs-ascend/descend (9S-A/D) tests. Known-groups validity was examined using TUG score (cut-off 13.5 s) as an estimate variable. Responsiveness was examined before and 4 weeks after direct anterior minimal invasive surgery. RESULTS: Reliability: Internal consistency was moderate (Cronbach's a = 0.614, p < 0.001). Test-retest reliability was excellent (ICC = 0.881, 95% CI, 0.824-0.920). Reproducibility: Floor and ceiling effects were both 1.1%; measurement error was 3.54 (p < 0.05); minimal important change was lower than minimal detectable change.Validity: mHHS-Gr correlated strongly with both LEFS-Greek and WOMAC-Gr (Pearson's r 0.801 and -0.783, respectively; p < 0.001). The questionnaire's correlations with TUG and 9S-A/D were also significant but moderate (Spearman's ρ: -0.547 and -0.575, respectively; p < 0.001). Known-groups validity showed that mHHS-Gr scores were significantly higher in participants with TUG < 13.5 seconds than in those with TUG > 13.5 seconds (p < 0.001). In ROC analysis, the cut-off point of 52.5 yielded sensitivity 81% and specificity 71%.Responsiveness: Standardised response mean and Guyatt's responsiveness statistic were greater than 0.8. DISCUSSION: mHHS-Gr showed significant moderate to excellent reliability, significant moderate to strong validity properties and excellent responsiveness. Overall, mHHS-Gr could be a reliable and valid PRO measure for assessing patients with osteoarthritis of the hip.

COMBSecretomics: A pragmatic methodological framework for higher-order drug combination analysis using secretomics.

Multi drug treatments are increasingly used in the clinic to combat complex and co-occurring diseases. However, most drug combination discovery efforts today are mainly focused on anticancer therapy and rarely examine the potential of using more than two drugs simultaneously. Moreover, there is currently no reported methodology for performing second- and higher-order drug combination analysis of secretomic patterns, meaning protein concentration profiles released by the cells. Here, we introduce COMBSecretomics (https://github.com/EffieChantzi/COMBSecretomics.git), the first pragmatic methodological framework designed to search exhaustively for second- and higher-order mixtures of candidate treatments that can modify, or even reverse malfunctioning secretomic patterns of human cells. This framework comes with two novel model-free combination analysis methods; a tailor-made generalization of the highest single agent principle and a data mining approach based on top-down hierarchical clustering. Quality control procedures to eliminate outliers and non-parametric statistics to quantify uncertainty in the results obtained are also included. COMBSecretomics is based on a standardized reproducible format and could be employed with any experimental platform that provides the required protein release data. Its practical use and functionality are demonstrated by means of a proof-of-principle pharmacological study related to cartilage degradation. COMBSecretomics is the first methodological framework reported to enable secretome-related second- and higher-order drug combination analysis. It could be used in drug discovery and development projects, clinical practice, as well as basic biological understanding of the largely unexplored changes in cell-cell communication that occurs due to disease and/or associated pharmacological treatment conditions.

International Hip Outcome Tool (12-items) as health-related quality-of-life measure in osteoarthritis: validation of Greek version.

BACKGROUND: The 12-item International Hip Outcome Tool (iHOT12) is a patient-reported outcome (PRO) designed to evaluate quality of life. We assessed the psychometric properties of the Greek version (iHOT12-Gr) in hip osteoarthritic patients. METHODS: Data from 124 patients aged > 50 years were used for factor analysis. Reliability evaluation included internal consistency, test-retest reliability, and interpretability. Content validity was examined by calculating the item-level content validity indices (I-CVI) and the scale-level content validity indices (S-CVI), using two methods: S-CVI Average (S-CVI/Ave), and the S-CVI Universal Agreement among experts (S-CVI/UA). Construct validity was tested against Greek versions of the Lower Extremity Functional Scale (LEFS-Greek), Modified Harris Hip Score (MHHS-Gr), and the 30 s chair-to-stand, Timed Up & Go (TUG), and 9-stairs-ascend/descend (9S-A/D) tests. Known-groups validity was examined using LEFS-Greek (cut-off = 53 points) as estimate variable. Responsiveness was examined pre and post total hip arthroplasty (4 and 8 weeks). RESULTS: Factor analysis revealed a two-factor model. Factor-1 (items 1-9) reflects "Symptoms and functionality", while Factor-2 (items 10-12) reflects "Hip disorder-related concerns". Reliability: Internal consistency and test-retest reliability of iHOT12-Gr-total were excellent: Cronbach's alpha > 0.92 and ICC(95% CI) > 0.976(0.96-0.99)(p < 0.001). Interpretability: There was no floor or ceiling effect; measurement error: 3.72 (Factor-1), 3.64 (Factor-2), and 3.22 (iHOT12-Gr-total); minimal detectable change: 10.3 (Factor-1), 10.1 (Factor-2), and 8.92 (iHOT12-Gr-total). VALIDITY: Content validity: The I-CVI value of the 12 items ranged from 1.00 to 0.83, the S-CVI/Ave was 0.97 and the S-CVI/UA was 0.83. Construct validity: iHOT12-Gr correlated strongly with both LEFS-Greek and MHHS-Gr, and weakly but significantly with 30s chair-to-stand, TUG and 9S-A/D (p < 0.001). Known-groups validity showed that iHOT12-Gr well discriminated subgroups of patients (p < 0.001). ROC analysis cut-off points were 51.9 (Factor-1), 25 (Factor-2) and 45.2 (iHOT12-Gr-total) (p < 0.001). Responsiveness: Four and 8 weeks postoperatively, standardized response means of Factor-1, Factor-2, and iHOT12-Gr-total were > 0.8. CONCLUSION: iHOT12-Gr showed excellent reliability properties. The content validity was excellent and significant weak-to-strong correlations were found regarding construct validity. The known-group validity was also significant, while the responsiveness was excellent. iHOT12-Gr could be a reliable and valid PRO for assessing quality of life in patients with hip osteoarthritis.