Can Patients Who Have Low-Grade Hip Osteoarthritis Expect the Same Outcome After Total Hip Arthroplasty Compared to Those Who Have End-Stage Osteoarthritis? - A Matched Case-Control Study.

BACKGROUND: Total hip arthroplasty (THA) is an effective procedure for patients with end-stage hip osteoarthritis (OA). In addition, when hip preservation surgery is no longer indicated due to the presence of early or mild arthritic changes, THA can also be considered. Whether these patients can expect the same outcome after THA as patients who have end-stage OA remains unclear. The goal of this study was to compare the clinical outcomes after THA of patients who have low-grade OA versus a matched cohort with end-stage OA. METHODS: This is a retrospective, single-center, multisurgeon case-control study in a high-volume referral center. Based on a cohort of 2,189 primary anterior approach THAs (1,815 patients), 50 low-grade OA cases were matched 1:1 by age, sex, and body mass index to 50 controls who have end-stage OA. Patient-reported outcome measures (PROMs) were Hip Disability and Osteoarthritis Outcome Scores and Short Form-36. RESULTS: No significant differences in preoperative PROMs between low-grade and end-stage OA patients were found, except for 36-item Short Form Survey pain (33.0 versus 41.0; P = .045). In both groups a significant improvement of all PROMs was found postoperatively. However, all Hip Disability and Osteoarthritis Outcome Scores were significantly lower in the low-grade OA group compared to the end-stage OA group. In the group with low-grade OA, a significantly lower percentage of patients achieved the minimal clinically important difference and substantial clinical benefit after THA compared to the group with end-stage OA. CONCLUSIONS: Patients who have low-grade OA can expect substantial clinical improvement after THA. However, the improvement is lower compared to patients who have end-stage OA. A thorough understanding of the factors that may lead to inferior clinical outcomes is imperative to improving the indications for THA in individuals who have low-grade OA.

The effect of spinal versus general anaesthesia on perioperative muscle weakness in patients having bilateral total hip arthroplasty: a single center randomized clinical trial.

BACKGROUND: Perioperative neuro-endocrine stress response may contribute to acquired muscle weakness. Regional anaesthesia has been reported to improve the outcome of patients having total hip arthroplasty. In this study, it was hypothesized that spinal anaesthesia (SA) decreases the perioperative neuro-endocrine stress response and perioperatively acquired muscle weakness (PAMW), as compared to general anaesthesia (GA). METHODS: Fifty subjects undergoing bilateral total hip arthroplasty (THA) were randomly allocated to receive a standardized SA (n = 25) or GA (n = 25). Handgrip strength was assessed preoperatively, on the first postoperative day (primary endpoint) and on day 7 and 28. Respiratory muscle strength was measured by maximal inspiratory pressure (MIP). Stress response was assessed by measuring levels of Adrenocorticotropic hormone (ACTH), cortisol and interleukin-6 (IL-6). RESULTS: Handgrip strength postoperatively (day 1) decreased by 5.4 ± 15.9% in the SA group, versus 15.2 ± 11.7% in the GA group (p = 0.02). The handgrip strength returned to baseline at day 7 and did not differ between groups at day 28. MIP increased postoperatively in patients randomized to SA by 11.7 ± 48.3%, whereas it decreased in GA by 12.2 ± 19.9% (p = 0.04). On day 7, MIP increased in both groups, but more in the SA (49.0 ± 47.8%) than in the GA group (14.2 ± 32.1%) (p = 0.006). Postoperatively, the levels of ACTH, cortisol and IL-6 increased in the GA, but not in the SA group (p < 0.004). CONCLUSION: In patients having bilateral THA, SA preserved the postoperative respiratory and peripheral muscle strength and attenuated the neuro-endocrine and inflammatory responses. TRIAL REGISTRATION: clinicaltrials.gov NCT03600454.

Clinical phenotypes and prognostic factors in persons with hip osteoarthritis undergoing total hip arthroplasty: protocol for a longitudinal prospective cohort study (HIPPROCLIPS).

BACKGROUND: Large heterogeneity exists in the clinical manifestation of hip osteoarthritis (OA). It is therefore not surprising that pain and disability in individuals with hip OA and after total hip arthroplasty (THA) cannot be explained by biomedical variables alone. Indeed, also maladaptive pain-related cognitions and emotions can contribute to pain and disability, and can lead to poor treatment outcomes. Traumatic experiences, mental disorders, self-efficacy and social support can influence stress appraisal and strategies to cope with pain, but their influence on pain and disability has not yet been established in individuals with hip OA undergoing THA. This study aims (1) to determine the influence of traumatic experiences and mental disorders on pain processing before and shortly after THA (2) to identify preoperative clinical phenotypes in individuals with hip OA eligible for THA, (3) to identify pre- and early postoperative prognostic factors for outcomes in pain and disability after THA, and (4) to identify postoperative clinical phenotypes in individuals after THA. METHODS: This prospective longitudinal cohort study will investigate 200 individuals undergoing THA for hip OA. Phenotyping variables and candidate prognostic factors include pain-related fear-avoidance behaviour, perceived injustice, mental disorders, traumatic experiences, self-efficacy, and social support. Peripheral and central pain mechanisms will be assessed with thermal quantitative sensory testing. The primary outcome measure is the hip disability and osteoarthritis outcome score. Other outcome measures include performance-based measures, hip muscle strength, the patient-specific functional scale, pain intensity, global perceived effect, and outcome satisfaction. All these measurements will be performed before surgery, as well as 6 weeks, 3 months, and 12 months after surgery. Pain-related cognitions and emotions will additionally be assessed in the early postoperative phase, on the first, third, fifth, and seventh day after THA. Main statistical methods that will be used to answer the respective research questions include: LASSO regression, decision tree learning, gradient boosting algorithms, and recurrent neural networks. DISCUSSION: The identification of clinical phenotypes and prognostic factors for outcomes in pain and disability will be a first step towards pre- and postoperative precision medicine for individuals with hip OA undergoing THA. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05265858. Registered on 04/03/2022.

Acetabular defect management and revision arthroplasty via the direct anterior approach.

OBJECTIVE: Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. INDICATIONS: Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. CONTRAINDICATIONS: Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. SURGICAL TECHNIQUE: Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. POSTOPERATIVE MANAGEMENT: Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. RESULTS: Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.

Femoral revision with the direct anterior approach.

OBJECTIVE: The advantages of the direct anterior approach (DAA) in primary total hip arthroplasty as a minimally invasive, muscle-sparing, internervous approach are reported by many authors. Therefore, the DAA has become increasingly popular for primary total hip arthroplasty (THA) in recent years, and the number of surgeons using the DAA is steadily increasing. Thus, the question arises whether femoral revisions are possible through the same interval. INDICATIONS: Aseptic, septic femoral implant loosening, malalignment, periprosthetic joint infection or periprosthetic femoral fracture. CONTRAINDICATIONS: A draining sinus from another approach. SURGICAL TECHNIQUE: The incision for the primary DAA can be extended distally and proximally. If necessary, two releases can be performed to allow better exposure of the proximal femur. The DAA interval can be extended to the level of the anterior superior iliac spine (ASIS) in order to perform a tensor release. If needed, a release of the external rotators can be performed in addition. If a component cannot be explanted endofemorally, and a Wagner transfemoral osteotomy or an extended trochanteric osteotomy has to be performed, the skin incision needs to be extended distally to maintain access to the femoral diaphysis. POSTOPERATIVE MANAGEMENT: Depending on the indication for the femoral revision, ranging from partial weight bearing in cases of periprosthetic fractures to full weight bearing in cases of aseptic loosening. RESULTS: In all, 50 femoral revisions with a mean age of 65.7 years and a mean follow-up of 2.1 years were investigated. The femoral revision was endofemoral in 41 cases, while a transfemoral approach with a lazy­S extension was performed in 9 patients. The overall complication rate was 12% (6 complications); 3 patients or 6% of the included patients required reoperations. None of the implanted stems showed a varus or valgus position. There were no cases of mechanical loosening, stem fracture or subsidence. Median WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score before surgery improved significantly from preoperative (52.5) to postoperative (27.2).

Extra-Articular Impingement at the Anterior Inferior Iliac Spine: A Cause of Refractory Periarticular Pain After Total Hip Arthroplasty.

BACKGROUND: Periarticular pain after total hip arthroplasty (THA) can significantly impair the postoperative functionality. Extra-articular impingement between the greater trochanter and the anterior inferior iliac spine is presented as a cause of refractive pain after THA. METHODS: Twenty patients were treated for refractive periarticular pain and limited internal rotation between January 2014 and April 2016. All patients underwent a positive chair rise test, pelvic inclination test, and Marcainisation test. Patients were treated with bone resection of the anterior part of the greater trochanter with or without component revision. RESULTS: At a mean follow-up of 20 months, all functional outcomes had improved significantly. All patients were willing to undergo the surgery again. Sixteen (80%) indicated the result as very good, 3 (15%) as good, and one (5%) as poor. Two patients developed a postoperative heterotopic ossification that required resection. CONCLUSIONS: Extra-articular impingement should be considered as a possible cause of refractive groin pain after THA. Bony resection through the Hueter interval provides immediate pain relief with improved functional outcomes 1 year after surgery.

Gluteus Maximus Transfer as an Augmentation Technique for Patients With Severe Abductor Deficiency of the Hip.

Impaired abductor function of the hip following severe abductor deficiencies can be devastating for functionality and quality of life. Recently, gluteus maximus transfer has been proposed as a solution to these difficult problems. However, outcome results are sparse. The aim of this study was to evaluate the effects of gluteus maximus transfer on improvement of pain, disability, and quality of life in patients with severe hip abductor deficiencies. Gluteus maximus transfer was performed in 16 patients with severe disruption of the abductor muscles of the hip. Data were collected preoperatively and at 6 weeks, 3 and 6 months, and 1 to 2 years after surgery. The measurements pertained to complications, healing of the flap based on magnetic resonance imaging (MRI) findings (in 10 patients), evaluation of Trendelenburg gait and sign, and patient-reported outcome measures of pain, disability, and quality of life. Preoperatively, all patients had a positive Trendelenburg sign and reported severe pain at the level of the greater trochanter. At a mean follow-up of 20 months, the Trendelenburg sign was negative in 7 patients and the Trendelenburg gait had disappeared in 7 patients. There was an improvement in patient-reported outcome measures but not to a significant level except for the pain subscores. Two patients had a postoperative seroma that resulted in a visible bump on the lateral side. Seven of 10 repairs with MRI follow-up showed perfect ingrowth on MRI without signs of rerupture. Gluteus maximus transfer for abductor deficiency of the hip may be effective for pain relief and functional improvements. Most patients showed an improved quality of life but were not completely pain free. [Orthopedics. 2020;43(4):e299-e305.].

Extensile Direct Anterior Approach to the Hip for Severe Acetabular Defects.

Although total hip arthroplasty (THA) surgery is one of the most successful procedures in orthopaedics, the number of revision procedures is predicted to increase by 137% over the next two decades.1 Implant failure modes such as instability, infection, loosening, and wear are becoming more prevalent.2 Instability, infection, extensive bony defects, and soft-tissue damage are the most important concerns and complications associated with revision surgery. More than 50% of revisions involve the acetabular implant.2 Paprosky et al described a classification of acetabular defects that occur in cases of implant failure.3 Treating type 2 and 3 uncontained defects can be technically challenging because the surgeon has to use extensive reconstruction techniques to adequately restore the biomechanics of the hip, structural stability, and leg length. Furthermore, neurovascular structures can be in jeopardy when complex pelvic reconstructive procedures are being conducted. In an attempt to optimize the access to the pelvic bone, to minimize soft-tissue damage and to protect the pelvic neurovascular structures, we use an extensile anterior approach to the acetabulum. This approach has been described by Ganz et al to conduct periacetabular osteotomies (PAO).4,5 This approach uses the Smith Petersen interval and exposes the anterior column and the acetabulum along with its defects. To our knowledge, the approach has not been used or described yet to conduct complex reconstructive surgeries for extensive acetabular defects in THA. The following is a description of a modified extensile surgical technique for challenging acetabular defects that may be encountered in certain revision THA reconstructions, as well as certain primary THA. This is an enhanced technical description of a technique presented by these authors in a previously described series of 48 patients who underwent revision using these techniques.6.

Large head ceramic-on-ceramic bearing in primary total hip arthroplasty: average 3-year follow-up of a multicentre study.

BACKGROUND: Surgeons are increasingly using larger femoral head sizes in total hip arthroplasty (THA) to improve stability and reduce the rate of dislocation, 1 of the leading causes of revision surgery. Large ceramic head sizes up to 48 mm can now be used with monoblock acetabular components. National registries have shown promising results at short-term with large diameter ceramic-on-ceramic THA, with very low revision rates.This study reports on the average 3-year follow up of a press-fit monoblock large diameter acetabular shell with a pre-assembled ceramic liner, with emphasis on the radiographic outcome, complications related to the implantation of the cup, and the patient's clinical outcome. METHODS: 170 hips in 169 patients were reviewed at an average 38 ± 5.8 months following surgery. RESULTS: The radiographic review revealed no acetabular cup loosening, no osteolysis and no cup migration. 1 acetabular cup was revised for malposition. The patient clinical outcome and the satisfaction rate were excellent. At 3 years, 7.1% of patients complained of groin pain and 3.5% spontaneously reported hip joint generated noise. 1 patient sustained a non-recurrent traumatic hip dislocation 2 years post surgery. CONCLUSIONS: New technology should be introduced cautiously on the market. This is especially true for the large diameter ceramic monoblock acetabular component used in this study since it involves a new acetabular component design. At short term, we have not identified new modes of failure with this implant. Longer follow-up is still needed to assess the safety of large ceramic bearing in THA.

Normative Functional Outcomes as a New Outcome Assessment Tool Following Hip Procedures.

Patient-reported outcome measures play an important role in evaluating the functional outcome of surgical and nonsurgical treatments of the hip joint. One thousand healthy volunteers completed the modified Harris hip score, the University of California, Los Angeles score, the Hip Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index score. Between September 2010 and December 2015, a total of 127 periacetabular osteotomies were performed in 111 patients with symptomatic developmental dysplasia of the hip. Forty-two of these patients (10 male and 32 female) met inclusion criteria. Mean follow-up was 32 months (range, 13-59 months). Pre- and postoperative radiographic analysis of the lateral center-edge angle and the acetabular index was conducted in all cases with a proper pelvic anteroposterior radiograph. The patients completed the modified Harris hip score, the University of California, Los Angeles score, the Hip Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index score. The authors investigated the influence of various confounding variables to (1) obtain recommendations when outcome scores are being compared between 2 cohorts and (2) define a normative reference level of "hip-healthy" functionality. This normative level of functionality was used as a target level of functionality following a hip procedure such as periacetabular osteotomy. All functional outcome scores had significantly improved 1 year after periacetabular osteotomy; thus, patients were much better than preoperatively. However, only 55% achieved the 95% functionality of the normative population based on modified Harris hip score and University of California, Los Angeles score. The results were worse for the Hip Osteoarthritis Outcome Score subscales. This approach places the results of surgical procedures in a different but potentially more realistic perspective in terms of expectations and goals. [Orthopedics. 2018; 41(5):e663-e670.].

A Modified Extensile Anterior Approach to the Acetabulum for Severe Acetabular Defects.

A modified extensile Smith-Petersen approach was used to access the acetabulum and pelvis in cases with complex acetabular defects requiring extensive reconstructions. Between 2010 and 2014, a total of 49 hips (48 patients) with a variety of acetabular defects were reconstructed using highly porous hemispherical acetabular cups and different reconstruction methods. Preoperative diagnoses included isolated aseptic loosening of the acetabular component, aseptic loosening of both acetabular and femoral components, infection, and other. Five patients (5 hips) died prior to the 2-year follow-up, with death being unrelated to the index operation. Mean follow-up of the remaining 44 hips was 40 months. There were no intraoperative complications. Ten patients had postoperative complications; all occurred within the first 12 months postoperatively. Complications occurred in 30% and 70% of type 2 and type 3 defects, respectively. Half of the complications were treated nonoperatively. The all-cause reoperation rate was 10%. All implants were radiographically stable. The modified extensile anterior approach to the acetabulum and pelvis is safe and allows for excellent exposure and successful reconstruction of bony defects. The exposure is less successful in addressing instability due to abductor or soft tissue deficiencies, with a re-revision rate of 4% to a constrained liner for recurrent instability. Seventy percent of all complications and 83% of all dislocations occurred in the Paprosky type 3 defect group. To decrease complications with a complex acetabular defect and associated deficiency of the abductor mechanism and soft tissue constraints, a constrained liner or dual mobility socket should be considered to simultaneously address both bony defects and soft tissue deficiencies. [Orthopedics. 2018; 41(2):e194-e201.].

Longitudinal joint loading in patients before and up to one year after unilateral total hip arthroplasty.

Abnormal kinematics and kinetics have been reported in hip osteoarthritis (OA) patients before and after total hip arthroplasty (THA). These changes can affect the loading of the ipsilateral hip, as well as the contralateral hip and knee joint. As it is not clear how hip and knee loading evolves in THA patients during the first year after surgery, the goal of this study is to define how joint loading changes in patients before and at three evaluation times after THA surgery. Musculoskeletal modelling in combination with gait analysis data was used to calculate hip and knee contact forces in 14 patients before and 3-, 6- and 12-months after unilateral THA, as well as in 18 healthy controls. Results showed that bilateral hip and knee loading were decreased compared to controls, both before and after THA surgery. Loading symmetry was altered compared to controls at 3-months post-surgery for the hip and at all evaluation times, except for 6-months post-surgery, for the knee, with ipsilateral joint loading decreased compared to the contralateral side. To conclude, 12-months after THA joint loading was not normalized, with both hip and knee loading in patients decreased compared to controls. Therefore, no overloading of the ipsi- or contralateral hip and knee joint was found before and up to one year after unilateral THA.

Is there a place for conservative treatment of a Vancouver B2 fracture around a cemented polished tapered stem?

Revision of the unstable stem of a total hip replacement following a peri-prosthetic fracture of the femur is a complex procedure with a high complication rate. With this study we aim to describe the radiologic findings of a specific fracture around polished tapered cemented stems and we present the results of a two- stage treatment plan for non-displaced Vancouver type B2 fractures. Eight male patients with a cemented polished, tapered stem presented after a fall. Standard radiographs did not show any direct signs of a fracture. CT scans showed a complex burst fracture with cement mantle cracks in all cases. Partial weight bearing with 2 crutches was initiated for at least 6 weeks. A cement- in-cement revision was conducted at 3 months in case the patient was not pain free. After 3 months of weight bearing as tolerated, none of the fractures had displaced any further, neither had the stem further subsided. Five patients were pain free and did not require surgical intervention. One patient underwent a cement-in-cement stem revision because of persistent pain. Normal radiographs of a post-traumatic and painful polished tapered stem do not exclude a Vancouver type B2 fracture and should be followed by a CT-scan. Cement cracks, eccentric gaps and subsidence are highly suspicious signs for a non-displaced fracture pattern. Conservative treatment remains an option for these fractures and can be followed by a cement- in-cement stem revision after fracture healing, if this is still required.

Distal Extension of the Anterior Approach to the Hip Using the Femoral Interbundle Technique: Surgical Technique and Case Series.

BACKGROUND: The direct anterior approach (DAA) is becoming more popular as the standard surgical approach for primary total hip arthroplasty. However, it has been associated with an increased incidence of intraoperative femoral fractures in particular during the learning curve. Distal extension of the approach may be needed in case of intraoperative complications. The aim of the present study is to describe the distal extension of the DAA using the femoral interbundle technique. METHODS: A stepwise approach based on a cadaveric study to extend the DAA distally is presented. The interval between the neurovascular bundles running to the vastus lateralis is used to gain access to the femur. Clinical and electromyography results of 5 patients undergoing a revision of the femoral component through an extended anterior approach are reported. RESULTS: In 2 cases, the proximal bundle was exposed whereas in 3 cases the interval between the proximal and distal bundle was developed and cerclage wires were applied around the isthmus of the femur. All fractures had healed at 6 months of follow-up. Four cases had a normal electromyography, and 1 case demonstrated a neuropraxia of a branch to the vastus lateralis. All cases had a 5/5 extension power of the quadriceps muscle clinically. CONCLUSION: The interbundle technique is an alternative way to gain additional exposure of the femur during the DAA and is based on precise knowledge of the periarticular neurovascular structures. This approach can be helpful to safely deal with intraoperative complications such as fractures requiring proximal femoral cerclage wiring during the anterior approach.

Addition of Liposome Bupivacaine to Bupivacaine HCl Versus Bupivacaine HCl Alone for Interscalene Brachial Plexus Block in Patients Having Major Shoulder Surgery.

BACKGROUND AND OBJECTIVES: We examined whether liposome bupivacaine (Exparel) given in the interscalene brachial plexus block lowers pain in the setting of multimodal postoperative pain management for major shoulder surgery. METHODS: Fifty-two adult patients were randomized to receive either 5 mL of 0.25% bupivacaine HCl immediately followed by 10 mL of liposome bupivacaine 133 mg (n = 26) or 15 mL of 0.25% standard bupivacaine alone (n = 26) in interscalene brachial plexus block. The primary outcome (worst pain in the first postoperative week) was assessed by the Modified Brief Pain Inventory short form. Secondary outcomes were overall satisfaction with analgesia (OBAS), functionality of the surgical arm, sleep duration, time to first opioid (tramadol) request and opioid consumption (mEq), sensory-motor block characteristics, and the occurrence of adverse effects. RESULTS: Worst pain was lower in patients given liposome bupivacaine added to standard bupivacaine than in patients given standard bupivacaine alone (generalized estimating equation [GEE] estimated marginal mean values, 3.6 ± 0.3 vs 5.3 ± 0.4 points on the Numeric Rating Scale, respectively, although the effect was modest, 1.6 ± 0.5; 95% confidence interval, 0.8-2.5). Total OBAS scores indicated greater satisfaction (GEE estimated marginal mean values, 1.8 ± 0.3 vs 3.3 ± 0.4 on total OBAS, respectively, with modest effect, difference, 1.4 ± 0.5; 95% confidence interval, 0.5-2.4). There were no differences in any of the other secondary outcomes. CONCLUSIONS: Liposome bupivacaine added to standard bupivacaine may lower pain and enhance patient's satisfaction in the first postoperative week even in the setting of multimodal analgesia for major shoulder surgery.This study was registered with clinicaltrials.gov (NCT02554357) on July 11, 2015, by Principal Investigator Catherine Vandepitte, MD.

The Direct Anterior Approach for Complex Primary Total Hip Arthroplasty: The Extensile Acetabular Approach on a Regular Operating Room Table.

BACKGROUND: The direct anterior approach on a regular operating room table has been reported with low dislocation rates. This might be beneficial for complex primary total hip arthroplasty (THA) such as in patients with cerebral palsy or following femoral or pelvic osteotomies. Extending the approach is often required to overcome problems such as acetabular deformities or severe contractures. METHODS: We retrospectively evaluated the results and complications of 29 patients with 37 complex primary THA in which an extensile approach was used. The extensile approach is described. Functional scores were collected in case the patient was ambulatory independently (n = 17). RESULTS: The average age was 35 years (range 15-85) with a mean follow-up of 39 months (range 12-60). There were 3 (8%) intra-operative and 4 (11%) early post-operative complications (<3 months), of which 3 (8%) were anterior dislocations. Late complications (>3 months) consisted of a fibrous ingrown stem, a socket loosening following a pelvic fracture, and a late hematogenous infection (8%). Seventy-one percent of the complications occurred in the first 18 cases (49%) indicating a learning curve. The mean post-operative Harris Hip Score was 79 (range 56-97). CONCLUSION: Complex THA can be safely conducted through the extensile anterior approach on a regular operating room table with the use of conventional implants, even in cases with a high risk of dislocation.

Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws.

BACKGROUND: Distal biceps tendon repair to the radial tuberosity can be conducted by means of an interference screw in combination with a transosseous button. Bioabsorbable interference screws have been associated with complications such as severe osteolytic reactions. We questioned whether patients with a distal biceps tendon repair with bioabsorbable poly-L-lactide (PLLA) screws had different functional, clinical, and radiologic outcome than patients with nonabsorbable poly-ether ether ketone (PEEK) screws. METHODS: Between 2010 and 2014, 23 patients with an acute distal biceps tendon rupture were treated with reinsertion of the distal biceps tendon in a bone tunnel at the radial tuberosity through a single anterior incision using a transosseous button combined with an interference screw. A PLLA screw was used in 12 patients and a PEEK screw in 11 patients. All patients were retrospectively evaluated with a minimal follow-up of 1 year clinically and by means of the visual analog scale for pain, Mayo Elbow Performance Score, and Disabilities of Arm, Shoulder and Hand Outcome Measure score. Bone tunnel volume was measured with computed tomography segmentation. RESULTS: Elbow mobility and arm and forearm circumference were symmetric for all patients. The visual analog scale for pain was 0.2 in the PLLA group and 0.7 in the PEEK group. The Disabilities of Arm, Shoulder and Hand score and Mayo Elbow Performance Score were 5.4 and 98.7 in the PLLA group vs. 3.1 and 95.9 in the PEEK group. Bone tunnel enlargement of 43% in the PLLA and 38% in the PEEK group was noted. CONCLUSIONS: Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both groups. Bone tunnel widening occurred in all patients.

Inflammatory Neuropathy of the Lumbosacral Plexus following Periacetabular Osteotomy.

Introduction. During periacetabular osteotomy (PAO), the sciatic, femoral, and obturator nerves are at risk. Most frequently nerve lesions can be attributed to a mechanical cause; however, in the absence of a clear mechanical cause surgeons are faced with a diagnostic problem and in many cases no diagnosis will be established. We report a case of inflammatory neuropathy of the lumbosacral plexus following a PAO. Case Presentation. A 31-year-old female developed weakness of ankle and knee flexion and extension 6 months after a PAO. Electrophysiological studies revealed damage to the obturator, femoral, and sciatic nerve consistent with an inflammatory lumbosacral plexopathy. MRI of the lumbosacral plexus was normal. The patient was treated with multimodal pain therapy and prolonged physiotherapy; nevertheless, symptoms worsened over time. At 2-year follow-up, there were no signs of recovery. Discussion. Inflammatory neuropathy of the lumbosacral plexus is a potential cause of pain and weakness after ipsilateral orthopaedic procedures. It should be distinguished from more frequently encountered mechanical causes of postsurgical neuropathy based on clinical suspicion, electrophysiological studies, MRI, and nerve biopsy. It is important that the orthopaedic community is aware of this complication since there is some evidence that early recognition and initiation of immunosuppressive therapy can lead to improved clinical outcome.

Does surgical approach or prosthesis type affect hip joint loading one year after surgery?

Several approaches may be used for hip replacement surgery either in combination with conventional total hip arthroplasty (THA) or resurfacing hip arthroplasty (RHA). This study investigates the differences in hip loading during gait one year or more after surgery in three cohorts presenting different surgical procedures, more specific RHA placed using the direct lateral (RHA-DLA, n=8) and posterolateral (RHA-PLA, n=14) approach as well as THA placed using the direct anterior (THA-DAA, n=12) approach. For the DAA and control subjects, hip loading was also evaluated during stair ascent and descent to evaluate whether these motions can better discriminate between patients and controls compared to gait. Musculoskeletal modelling in OpenSim was used to calculate in vivo joint loading. Results showed that for all operated patients, regardless the surgical procedure, hip loading was decreased compared to control subjects, while no differences were found between patient groups. This indicates that THA via DAA results in similar hip loading as a RHA via DLA or PLA. Stair climbing did not result in more distinct differences in hip contact force magnitude between patients and controls, although differences in orientation were more distinct. However, patients after hip surgery did adjust their motion pattern to decrease the magnitude of loading on the hip joint compared to control subjects.

What is the best way to fix a polyurethane meniscal scaffold? A biomechanical evaluation of different fixation modes.

PURPOSE: Ingrowth of meniscal tissue into a meniscal scaffold can be optimized by securely fixing the scaffold into the meniscal remnants. The purpose of this research was to test and compare commonly used suture types and suture materials to fix a meniscal scaffold. METHODS: Forty fresh porcine menisci were used. All tests used the same polyurethane-based scaffold. The load to failure of horizontal, vertical and diagonal sutures with PDS 0 and with Ethibond 0, and diagonal sutures with Ultra Fast-Fix(®) and Sequent(®) to fix a meniscal scaffold were tested. Five tests were conducted for each configuration. RESULTS: All constructs failed in the scaffold at a mean pullout force of 50.6 N (SD 12.7). Inferior results were noted for vertical sutures (40.1 N, SD 6.3) compared to horizontal (49.8 N, SD 5.5, p = 0.0007) and diagonal (51.7 N, SD 15.6, p = 0.024) sutures and for Ethibond 0 (41.4 N, SD 6.2) compared to PDS 0 (51.3 N, SD 12.9, p = 0.001). When comparing the diagonal suture placements, only Ethibond 0 (42.9 N, SD 5.4) showed significantly inferior results compared to PDS 0 (60.1 N, SD 16.9, p = 0.03), Ultra Fast-Fix(®) (60.1 N, SD 9.3, p = 0.004) and Sequent(®) (65.8 N, SD 4.4, p < 0.0001). CONCLUSIONS: The most common failure mode when fixing a polyurethane-based meniscal scaffold is suture pull-through of the scaffold in the distraction mode. This happens at a rather low pullout force and might preclude the use of this scaffold clinically. Vertical sutures and Ethibond 0 multifilament braided sutures fail at lower forces, and the tested commercial devices show promising results.