Is bicortical femoral pin insertion safe for Image-based Robotic Knee Arthroplasty Surgery ? A comparative complications analysis in 970 Consecutive Cases.

OBJECTIVES: Limited data exists on complications associated with robotic image-based system in knee arthroplasty. This study aims to document complications in robotic arm-assisted knee arthroplasties, and evaluate the system's safety by comparing two femoral pin insertion methods: bicortical diaphyseal with additional stab wounds, and unicortical metaphyseal placement through the main incision. METHODS: All patients undergoing primary knee arthroplasty with the image-based robotic system (Mako, Stryker, Mako Surgical Corp., Fort Lauderdale, FL, USA) from 1st March 2021 to 31st January 2024 with a minimum follow-up of 2 months were included. Demographics, system and non-system-related complications, as well as outcomes were recorded. Complications were categorized as either major (requiring a second surgical intervention) or minor. RESULTS: A total of 970 consecutive cases (median age 69.3 years) were analyzed. The unicortical group comprised 651 cases, while the bicortical group 319. The incidence of non-system-related complications was 2.37%, with the most common being joint stiffness (10 cases; 1.03%), followed by lateral femoral condyle fracture (4;0.41%). The overall incidence of system-specific complications was 1.03%. Pin-related femoral fractures occurred in 0.2% of cases, all postoperatively and in the unicortical group. There was no statistically significant difference between the femoral pin insertion-related complication rates among the two groups (0.3% in the unicortical, compared to 0% in the bicortical group; p-value= 0.3). Complications included tibia fracture (0.1%), delayed wound healing (0.2%), superficial wound infection (0.1%), tibia osteomyelitis (0.1%), and "exostosis" (0.2%). The major complications rate was 0.3% and minor 0.7%. CONCLUSIONS: Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe. The bicortical diaphyseal femoral pin insertion method does not increase the complication rates compared to the unicortical metaphyseal method. LEVEL OF EVIDENCE: III.

Optimizing the patellofemoral compartment in total knee arthroplasty: Is it time for dynamic assessment?

Despite improvements in implant design, surgical techniques and assistive technologies for total knee arthroplasty (TKA), anterior knee pain (AKP) remains frequently reported, even by satisfied patients. This persistent problem calls for better understanding and management of the patellofemoral or anterior compartment during surgery, just as the techniques and strategies deployed to optimize the flexion and extension spaces through personalized alignment, bone cuts and ligament balancing. Assistive technologies such as navigation and robotics provide new tools to manage this 'third space' through precise pre-operative planning and dynamic intra-operative assessment. Such endeavors must start with clear definitions of the 'third space', how it should be measured, what constitutes its 'safe zone', and how it affects outcomes. There are yet no established methods to evaluate the patellofemoral compartment, and no clear thresholds to define over- or under-stuffing. Static assessment using lateral radiographs provides a limited understanding and depends considerably on flexion angle, while dynamic evaluation at multiple flexion angles or using intra-operative computer or robotic-assistance enables a broader perspective and solutions to manage patellar tracking and anterior offset. Future studies should investigate the impact of variations in anterior offset in TKA, define its safe zone, and understand the effects of of thresholds for over- or under-stuffing. Experimental methods such as in-vivo motion analysis and force sensors could elucidate the influence of anterior offset on flexion and extension biomechanics.

Similar complications and outcomes with simultaneous versus staged bilateral total hip arthroplasty with the direct anterior approach: A comparative study.

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

The Use of the Robotic Arm-Assisted System (MAKO) for Hip Revision Surgery.

The robotic arm-assisted system (MAKO) has pioneered a transformative approach to hip joint restoration, excelling in reinstating innate hip joint anatomy and biomechanics. This case represents the initial application of the system in revision surgery following a cut-out complication. A 69-year-old female, previously independent and mobile, presented with left hip pain. X-rays revealed a cut-out complication of the proximal nail, necessitating revision to total hip arthroplasty due to the patient's prior activity level and implant prominence. Utilizing the robotic system, preoperative planning accurately identified limb length discrepancy and guided implant sizing. The system facilitated precise acetabular reaming and optimal component placement. The patient regained functional independence. This report also underscores the system's potential for accurate acetabulum component placement and restoration of hip joint anatomy and biomechanics in revision cases. Future advancements in this technology may expand its role in complex reconstructions and revisions, further enhancing patient outcomes in hip arthroplasty.

Press-fit vs threaded acetabulum components for total hip arthroplasty - A systematic review with metanalysis.

Background: Threaded acetabular components (TACs) have been shown to offer greater initial stability compared to press-fit acetabular components (PFACs). Despite these biomechanical advantages, the use of threaded cups remains. This study compares the outcomes of TACs to PFACs in total hip arthroplasty (THA), providing evidence-based data regarding their failure rates and radiological evaluation. Methods: A meticulous research of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted, to identify all articles regarding the outcome of the use of TCAs compared to PFACs in THA. Subsequently, statistical analysis with metanalysis concerning: 1) the instances of revision due to aseptic loosening and 2) the radiological evaluations of TACs compared to PFACs and sensitivity analysis were performed. Results: This metanalysis encompassed seven studies, enrolling 7878 cases of THA utilizing PFAC, and 6684 cases using TAC. The overall odds ratio (OR) for revision due to aseptic loosening in THA using PFAC compared to TAC was 3.10 (95 % CI 0.37-25.72). Additionally, when assessing radiolucency findings across the same categories, the pooled OR was 0.53 (95 % CI 0.26-1.08). An examination of studies with larger sample sizes revealed no statistically significant variance. After adjusting for age, no substantial difference was detected. However, upon gender adjustment, it was observed that females undergoing THA with PFAC had a 5-fold risk of revision (OR = 5.26, 95 % CI 0.25-111.91, p-value = 0.29) compared to females with TAC, although without reaching statistical significance. Moreover, females exhibited a slightly elevated risk for revision due to aseptic loosening post-PFAC THA compared to males [(OR = 5.26, 95 % CI 0.25-111.91) (OR = 2.51, 95 % CI 0.01-1051.68) respectively], and for radiolucency findings [(OR 0.74, 95 % CI 0.20-1.11) (OR 0.29, 95 % CI 0.03-3.36) respectively]. Conclusions: The PFACs remain the main option for total hip reconstruction, while TACs might be a viable alternative, especially in cases of osteoporosis.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience.

Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.

Renal Artery Triplication: An Unusual Morphological Variant.

Renal vasculature depicts great morphological variability and clinical significance due to the great number of procedures performed on kidneys. The current imaging report presents a right-sided renal artery (RA) triplication and origin from the abdominal aorta (AA), which was incidentally identified during computed tomography angiography (CTA). The typical RA corresponded to the main hilar artery (MHA), the second RA corresponded to the superior polar artery (SPA), and the third RA corresponded to the inferior polar artery (IPA). RA triplication occurs in 0.9%-4.5% and depicts wide morphological variability. The current report corresponds to one superior polar, one inferior polar, and a main hilar renal artery, which represents a rare morphological type of RA triplication. Kidney transplantation surgery, endoscopic surgery, and renal angiography require adequate knowledge of RAs and their variants to avoid pitfalls and iatrogenic lesions from clinicians.

Survivorship and Outcomes of Robotic Arm-Assisted Medial Unicompartmental Knee Arthroplasty at a Minimum of 5-Year Follow-Up.

PURPOSE: This study aimed to evaluate implant survivor-ship, complications, and re-operation rates following robotic arm-assisted unicompartmental knee arthroplasty (UKA) at mid-term follow-up. METHODS: Patient satisfaction, clinical outcome, and knee alignment restoration were evaluated. All patients undergo-ing robotic arm-assisted medial UKA during a 2-year period were prospectively enrolled. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, varus-valgus deformity, and knee range of motion were studied pre- and postoperatively. Revisions and surgery-related complications were recorded. RESULTS: Eighty-five patients were included in the study (mean age: 71.2 years). The mean follow-up was 74.7 months. One conversion to total knee arthroplasty was performed due to periprosthetic fracture 4.5 years after initial surgery result-ing in a survivorship rate of 98.8%. Overall satisfaction was excellent; 97.7% of patients were satisfied or very satisfied, while none was dissatisfied or very dissatisfied. WOMAC score in total, as well as in each component, exhibited sig-nificant improvement postoperatively. Additionally, knee alignment in the coronal plane as well as flexion contracture were significantly improved following the procedure. CONCLUSIONS: The outcomes of the present cohort revealed that precise prosthesis implantation through the robotic arm-assisted system in UKA provided excellent overall satisfac-tion rates and clinical outcomes at mid-term follow-up.

A Bilateral Symmetrical Variant Formation of the Sural Nerve.

Typically, the sural nerve is formatted by the connection of the lateral sural cutaneous nerve (branch of the common fibular nerve) and the medial sural cutaneous nerve (branch of the tibial nerve). The current cadaveric report aims to describe a quite unusual symmetrical variant of the sural nerve. Classical dissection was performed on an 84-year-old donated male cadaver. On both sides, the sural nerve was formatted directly by the sciatic nerve. After its emanation, it continued its typical course between the gastrocnemius muscle heads. Sural nerve formation has been extensively studied due to its great clinical significance. The identified variant corresponds to one of the rarest types of sural nerve formation. Knowledge of sural nerve variants may play a crucial role in lower limb surgery and nerve harvest for reconstruction.

Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm.

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

Restoring Hip Joint Anatomy With the Robotic Arm-Assisted System in Hip Fractures: Expanding the Applications for Hip Surgery.

Total hip arthroplasty (THA) has improved the life quality of osteoarthritic patients, yet challenges persist. The robotic arm-assisted system, integrated into THA, aims to refine implant positioning, enhance precision, reduce errors, and restore the hip joint's anatomy, including hip center, femoral offset, and limb length. We present the first use of the system for the treatment of a subcapital femoral neck hip fracture. A 62-year-old female suffering a left subcapital hip fracture underwent THA using the robotic arm-assisted system. After acetabular registration, accurate component placement was achieved, and a 9-mm limb length discrepancy was addressed. The patient had an unremarkable recovery with a reported Harris hip score of 96.5 at 18 months postsurgery. Robotic-guided navigation in THA, as showcased in this case, ensures accurate implant positioning by restoring the anatomical features of the hip joint. Its potential extends beyond conventional applications, hinting at future use in trauma, revision, and oncology cases. While promising, future adaptations should consider soft tissue dynamics to ensure joint stability and overall success.

Robotic Arm-Assisted Total Knee Arthroplasty: Anatomical Alignment and Mid-Term Outcomes from the First Cohort Originating in Greece.

Robotic arm-assisted total knee arthroplasty (RATKA) represents a haptic assistive robotic arm used for bone preparation. The purpose of this study was to present implant survivorship, complications and evaluate patients' satisfaction, clinical and functional outcome of RATKA with a minimum of 1-year follow-up. The Oxford Knee Score was recorded preoperatively and at last follow-up. Patients' satisfaction rates, as well as complications and re-operations were studied. Anatomical alignment including varus, valgus deformities and flexion, extension, pre-and postoperatively were evaluated. A total of 156 patients with mean age = 71.9 years were included in the study. The mean follow-up was 35.7 months, while one revision was performed due to infection. Statistically significant improvement of the Oxford Knee Score, as well as of the knee alignment deformities were recorded, while 99.4% of patients reported to be "very satisfied" or "satisfied" with the procedure. RATKA seems to be a safe, as well as reproductible procedure at short-and mid-term follow-up, while the accurate implant positioning may lead to favorable long-term outcomes.

Pitfalls with the MAKO Robotic-Arm-Assisted Total Knee Arthroplasty.

Robotic-arm-assisted total knee arthroplasty (RATKA) with the MAKO system minimizes deviations in implant alignment and yields superior precision in implant position compared to a manual total knee arthroplasty. In this comprehensive commentary, we present and categorize the limitations and pitfalls of the procedure and we also provide recommendations for avoiding each limitation. The main surgeon-related limitations include prolonged operation duration, loose insertion of the checkpoints and pins, wrong registration and mapping, and damage to soft tissues during bone cutting. The system-related issues include the interruptions of the saw-cutting due to vibrations, specifications for the operating room floor and power supply, the high cost of the system, as well as the cost of each operation due to the extra implants, inability to use the system with various prostheses, wireless connection interruptions between the system's components, and hardware issues with the six joints of the robotic device. In order to circumvent the potential challenges in this surgical procedure, it is essential to possess sufficient experience and undergo comprehensive training. Maintaining continuous awareness of the additional implants throughout the entire operation and prioritizing the preservation of soft tissues are of paramount significance. A profound comprehension of the system and its inherent constraints can also prove to be pivotal in certain situations.

Prior medial meniscus arthroscopy is not associated with worst functional outcomes in patients undergoing primary total knee arthroplasty: A retrospective single-center study with a minimum follow-up of 5 years.

INTRODUCTION: There have been controversial studies on the impact of prior knee arthroscopy (KA) on outcomes of total knee arthroplasty (TKA). The purpose of this comparative study is to investigate the impact of prior KA of medial meniscus on patients undergoing TKA by evaluating the International Knee Society Score (IKS), the complications, and revisions. METHODS: This retrospective study reviewed 84 patients with TKA who had undergone prior KA of the medial meniscus and compared them to 84 cases, without a history of prior KA as a control group. Outcomes were assessed with the original IKS scores and complications. The mean follow-up was 8 years. RESULTS: There was no significant difference between groups with respect to demographics, or pre-operative IKS. The mean pre and postoperative IKS was not different between groups. The all-cause reoperation, revision, and complication rates of the KA group were not significantly higher than those of the control group. CONCLUSION: The present study seems to reveal that previous KA of the medial meniscus does not negatively affect a subsequent TKA. Nevertheless, larger studies may be necessary to confirm this observation.

Hippocrates: A Pioneer in Orthopaedics and Traumatology.

PURPOSE: Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region. METHODS: The "Hippocratic Corpus" original text was thoroughly studied to identify all Hippocrates' contributions in Orthopaedics and Traumatology. Volume III of his works, especially "On Fractures", "On Joints", and "Mochlicon" includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system. RESULTS: In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures' healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases. CONCLUSIONS: Hippocrates' contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19th and 20th centuries.

Slipped Capital Femoral Epiphysis in Adolescents: Functional Outcomes and Return to Physical Activity after Surgical Treatment.

Background: Slipped capital femoral epiphysis (SCFE) represents a relatively common hip disorder in adolescents. The present retrospective study analyzes the correlation between age, severity of the slip and physeal stability and the functional outcomes, as well as the ability to return to previous physical activity (PA) of patients surgically treated with either pining in situ (PIS) or the modified Dunn (MD) procedure (anatomical reduction of the slipped epiphysis). Methods:The present research is a retrospective observational study of patients surgically treated for SCFE from 2010 to 2015. The sample was divided into two groups: those treated with PIS and those with the MD procedure. Univariate and multivariate logistic regression analyses were performed to determine the relationship between age, Loder classification (stable/unstable), as well as Southwick slip angle (severity of the slip) to return to previous PA. Furthermore, linear regression was used to investigate the association of the above predictor variables to Oxford and Harris hip scores (HHS). Results:A total of 32 patients were identified (16 treated with PIS and 16 with the MD procedure). None of the examined predictor variables (age, Southwick slip angle, Loder classification) had statistically significant effect on the ability to return to previous PA in either the in situ or Dunn group. Univariate analysis showed that higher patients' age at the time of surgery was related to worse HHS and Oxford scores in both the PIS and MD groups. Unstable hips seem to affect unfavorably the HHS. Conclusion:The present study did not reveal any relationship between the age, degree of the Southwick slip angle, the stability of the physis, and the return to PA. Exploration of additional confounding factors are warranted to better understand the physis-related impact on the functional outcomes in both groups.

The Coexistence of the Superficial Brachial Artery With the Common Origin of the Posterior Circumflex Humeral Artery and the Deep Brachial Artery.

The brachial artery (ΒΑ) represents the axillary artery's extension as it distally progresses to the teres major muscle or beneath the tendon of the latissimus dorsi muscle. Throughout its course, the BA maintains continuous proximity to the median nerve. Occasionally, an artery located in front of the arm muscles may exhibit a slightly more lateral position than the BA, following a convoluted path, referred to as the superficial brachial artery (SBA). SBA variants are not uncommon and can impact neural structures as well. In the course of routine dissection on a formalin-embalmed donated cadaver through the Body Donation Program, the following notable findings were identified: a) a BA bilateral trifurcation, below the tendon of the latissimus dorsi muscle; b) a posterior circumflex humeral artery of low origin (brachial artery); c) the coexistence of an SBA with the main BA; d) a subscapular artery of high origin (second part of the axillary artery); e) an anterior circumflex humeral artery duplication. These BA variants, particularly those related to the SBA, hold significance in upper limb surgery and everyday clinical practice. In such cases, meticulous surgical dissection is crucial to prevent arterial injury, and in complex situations, preoperative imaging might be advisable. Additionally, it's important to note that concurrent neural variants may also be present, potentially complicating the surgical approach.

Modified Anterolateral Minimally Invasive Surgery (ALMIS) for Total Hip Replacement: Anatomical Considerations, Range of Motion and Clinical Outcomes.

Background and Objectives: In the modified anterolateral minimally invasive surgery (ALMIS) for total hip arthroplasty (THA), the intermuscular plane between the tensor fasciae latae and the gluteus maximus (GM) is exposed, while the anterior » of the GM is detached. There are scarce data regarding this surgical approach. The purpose of the present study is to thoroughly describe this approach, encompassing the anatomical background, and to present the results of a retrospective two-center study of 603 patients. Materials and Methods: The present study includes a two-center retrospective observational cohort of 603 patients undergoing the ALMIS technique with minimum 5-year follow-up. Demographics were recorded, while range of motion (ROM) of the hip joint and the Harris Hip Score (HHS) were evaluated preoperatively, at 1, 3 and 12 months postoperatively and at the final follow-up (>5 years). Surgery-related complications were also recorded. Results: The studied population's mean age was 69.4 years, while most of them were females (397; 65.8%). The mean follow-up was 6.9 years. The median HHS at the 1-month follow-up was 74, compared to the 47 preoperatively (p-value < 0.0001). At the final follow-up, median HHS was 94. At the 1-month follow-up, mean adduction was 19.9° (compared to 15.4° preoperatively; p < 0.0001), mean abduction 24.3° (18.2° preoperatively; p < 0.0001), mean flexion 107.8° (79.1° preoperatively; p < 0.0001), mean external rotation 20.1° (12.1° preoperatively; p < 0.0001) and mean internal rotation 15.3° (7.2° preoperatively; p < 0.0001). ROM further improved until the final follow-up; mean adduction reached 22°, mean abduction 27.1°, mean flexion 119.8°, mean external rotation 24.4° and mean internal rotation 19.7°. Regarding complications, 1.3% of the sample suffered anterior traumatic dislocation, in 1.8% an intraoperative femoral fracture occurred, while 1.2% suffered periprosthetic joint infection. Conclusions: The modified ALMIS technique exhibited excellent clinical outcomes at short-, mid- and long-term follow-up, by significantly improving hip ROM and the HHS. Careful utilization of this technique, after adequate training, should yield favorable outcomes, while minimal major complications should be expected.

Suggestion of a Novel Classification Based on the Anatomical Region and Type of Bilateral Fatigue Femoral Fractures.

Purpose: Bilateral fatigue femoral fractures (BFFF) represent an extremely rare clinical entity. The present study introduces a novel classification, in order to categorize the BFFFs and provide a thorough review of all these, so far in the literature, reported cases. Methods: The BFFF were classified taking into account the anatomical region of the femoral fracture; (fh): femoral head, (sc): sub-capital, (pt): peri-trochanteric, (st): sub-trochanteric, (s): shaft, (d): distal femur and the fracture type (complete or incomplete); type I: bilateral incomplete fractures, type II: unilateral incomplete fracture, and type III: bilateral complete fractures. Type III was further subdivided into type IIIA: bilateral non-displaced fractures, type IIIB: unilateral displaced fracture, and type IIIC: bilateral displaced fractures. Furthermore, a meticulous review of the PubMed and MEDLINE databases was conducted to locate all articles reporting these injuries. Results: A total of 38 patients (86.8% males), with a mean age of 25.3 years, suffering BFFFs were identified from the literature search. The mean time interval from symptoms' onset to diagnosis was 54 days. According to the proposed classification, 2.6% of the fractures were categorized as type I (h), 36.8% as type I (sc), 2.6% as type I(st/s), 7.9% as type I (s), 2.6% as type I (d), 5.4% as type II (fh), 26.3% as type II (sc), 2.6% as type IIIA (st), 2.6% as type IIIA (d), 5.4% as type IIIB (sc), 2.6% as type IIIB (d) and 2.6% as type IIIC (sc). Surgery was performed in 52.6%, while non-operative treatment was followed in 47.4% of the population. Regarding the fracture type, 75% of type I fractures were conservatively treated, while 91.7% and 66.6% of type II and III fractures were surgically treated. For patients treated conservatively, the mean time from diagnosis to return to previous status was 260 days, while for patients treated surgically, 343 days. Conclusions: BFFFs, although rare, may pose a diagnostic and therapeutic challenge. The present classification offers valuable information and may act as a guide for the management of these patients.