Management of Osteoarthritis: Expert Opinion on NSAIDs.

Osteoarthritis (OA) is a leading cause of disability among older adults worldwide. Treatment aims are to alleviate inflammatory pain and improve physical function through non-pharmacological and pharmacological interventions. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy. However, selection is challenged by patient age, comorbidities and polypharmacy, and by the drug's benefit/risk balance, all of which together influence the risk of cardiovascular (CV), gastrointestinal (GI) and renal adverse events (AEs). While the efficacy profile of the various NSAIDs is delineated, the differences in their safety profile are not straightforward. This narrative review provides practical indications by a multidisciplinary Italian expert panel for general practitioners and specialists managing OA patients with chronic inflammatory pain; the goal is to maximize therapy efficacy while reducing untoward effects caused by inappropriate NSAID use. The discussion on the best approach to NSAIDs spanned the following topics: (1) patient evaluation: investigate pain origin, duration and components together with possible risk factors for CV, GI and renal AEs; (2) non-pharmacological interventions: the physiatrist provides a person-centered, holistic approach accounting for all patient aspects; (3) pharmacological interventions: patient profile and drugs' pharmacological properties affect NSAID selection, which drugs to be used in combination or to be avoided, formulation and therapy duration; (4) the pharmacologist's, general practitioner's and pain therapist's points of view; (5) NSAID safety: the individual baseline risk and the drug's safety profile are major determinants of CV, GI and renal risk; consider possible drug-drug interactions; (6) periodical re-evaluation of treatment response and adherence, using scales to assess pain and function.

Gait analysis: Comparative evaluation of conventional total knee replacement and modular distal femoral megaprosthesis.

BACKGROUND: Gait alterations have been studied with computer-assisted gait analysis after megaprosthetic replacement for tumors around the knee. It has never been proven that megaprostheses affects gait more than total knee arthroplasty (TKA); this study aims to compare via gait analysis patients who underwent megaprosthesis with patients with TKA. METHODS: We analyzed 26 patients with a megaprosthetic replacement of the distal femur and 21 patients with a standard TKA. For each subject computerized gait analysis was performed. Range of motion (ROM) of the knee was recorded, Quality of Life and functional evaluation in the oncologic group were assessed with the Musculoskeletal Tumor Society (MSTS) questionnaire, while Short Form-36 (SF-36) scores were calculated for both groups. RESULTS: All patients walked slower than healthy people (P < 0.05). Gait analysis showed a lower cadence than in the healthy population but no significant difference between the two groups. A longer swing and a shorter stance phase were detected in the megaprosthetic sample. The osteoarthritis group showed greater flexion during the phase of loading response, even if this was lower than the contralateral limb or healthy population. There was a statically significant difference between the healthy limb and the operated one in both groups regarding ROM, but no significant difference was registered between the two implants. MSTS score and most of SF-36 parameters showed no significant differences compared with literature data. CONCLUSIONS: Gait analysis shows little discrepancy between the two groups; gait pattern abnormalities do not affect patients with a megaprosthetic replacement more significantly than patients undergoing TKA.

Role of Bioelectrical Impedance Analysis in the Evaluation of Patients with Upper Limb Lymphedema.

Background: Monofrequency bioelectrical impedance analysis (BIA) protocols seek to further quantify changes in lymphedema compared with traditional circumferential evaluations. Complex decongestive therapy (CDT) is an effective method of reducing unilateral upper limb lymphedema secondary to breast cancer treatments. Comparing lymphedema measurements between segmental tetrapolar BIA, total body BIA, and circumferential measurements during therapeutic changes can improve our quantitative assessment ability for this prevalent medical complication. Methods and Results: Twenty-two patients with breast-cancer-related unilateral upper limb lymphedema participated in this prospective observational study. Circumferential measurements, segmental tetrapolar BIA, and total body BIA were obtained and compared before CDT, immediately after 10 sessions of CDT, and 30 days post-CDT to assess lymphedema. The segmental tetrapolar BIA correlated well with improvements in circumferential measurements of the limb. We found that the resistance value cutoff point of 237 Ω could indicate a recurrence of lymphedema. Conclusions: Segmental, tetrapolar monofrequency BIA provides a simple method to monitor and evaluate the efficacy of therapy in the outpatient setting by operators with minimal training. This protocol could aid quantitative evaluations of unilateral upper limb lymphedema.

Classes of vitamin D status and functional outcome after hip fracture: a prospective, short-term study of 1350 inpatients.

BACKGROUND: Vitamin D depletion is associated with unfavourable outcomes after hip fracture. However, the classes of vitamin D status currently in use, which are defined according to serum calcifediol levels, have not been validated for their predictive capability of the functional recovery. AIM: To investigate the association between serum calcifediol categorized into 4 classes and the functional recovery after hip fracture. DESIGN: Prospective, short-term observational study. SETTING: Rehabilitation hospital in Italy. POPULATION: We evaluated 1350 of 1412 inpatients with hip fracture. METHODS: Serum calcifediol was measured by an immunoenzymatic assay 14.7±4.4 (mean±SD) days after surgery and categorized into 4 classes: I class <12 ng/mL; II class 12-20 ng/mL; III class 21-29 ng/mL; IV class ≥30ng/mL. The functional outcome was assessed by using the Barthel Index. RESULTS: We found a significant difference in Barthel index scores at the end of inpatient rehabilitation across the 4 classes of vitamin D status: χ2 (3, N.=1350) 27.2; P<0.001. The difference persisted after adjustment for 8 covariates (P=0.004). By comparing pairs of classes, we found that Barthel index scores were lower in the 829 patients of the I class than in the 275 of the II (P=0.005) who had in turn Barthel index scores lower than the 132 patients of the III class (P=0.038). Conversely, no significant differences emerged between the patients of the III class and the 114 patients of the IV class (P=0.421). The results did not materially change when Barthel Index effectiveness was substituted for Barthel Index scores as the outcome measure. CONCLUSIONS: Calcifediol levels below 12ng/mL were associated with a worse recovery than those between 12 and 20ng/mL that were in turn associated with a worse recovery than those between 21 and 29 ng/mL. Conversely, no significant differences were found between the patients with calcifediol between 21 and 29ng/mL and those with calcifediol ≥30 ng/mL. CLINICAL REHABILITATION IMPACT: Despite caution due to the observational design, our study suggests that vitamin D depletion should be treated after hip fracture to optimize the functional outcome, with a target level for serum calcifediol of 21-29ng/mL and no further advantages associated with calcifediol levels of 30ng/mL or higher.

Does metal porosity affect metal ion release in blood and urine following total hip arthroplasty? A short term study.

INTRODUCTION: The surface area of exposed metal in a trabecular-titanium acetabular component is wider compared to traditional-titanium implants. The purpose of this study is to establish if this increase in surface area can lead to a significant increase in systemic metal levels. METHODS: 19 patients with conventional acetabular component and 19 with trabecular-titanium cup were compared. Aluminum, Vanadium and Titanium in blood and urine were assessed before surgery and at intervals for 2 years. The samples were analysed using an inductively coupled plasma mass spectrometry. RESULTS: Patients with trabecular-titanium did not have significantly higher metal ion levels compared to patients with conventional cups up to 2 years. A trend over time was statistically significant in both blood and urine for aluminum and titanium concentrations. CONCLUSIONS: The three-dimensionality and the wide surface of the trabecular-titanium acetabular component did not affect metal ion release compared to traditional implants after 2 years.

In Achilles tendinopathy, the neovascularization, detected by contrast-enhanced ultrasound (CEUS), is abundant but not related to symptoms.

PURPOSE AND HYPOTHESIS: Mid-portion Achilles tendinopathy is characterized by a proliferation of small vessels, called neovascularization, which can be demonstrated by power Doppler sonography (PD). Neovascularization can be correlated with diagnosis and consequent therapies focused on vascular supply. Published data regarding the relationship between neovascularisation and symptoms, such as pain and disability, are contradictory. The hypothesis that contrast-enhanced ultrasound (CEUS) could detect with more sensibility than PD the new vessel ingrowth in human degenerated Achilles tendons and therefore the correlation of neovascularization with pain and disability, was evaluated. METHODS: Thirty consecutive patients of recalcitrant Achilles tendinopathy were studied with ultrasound greyscale (US), PD, CEUS and magnetic resonance imaging. Neovascularization was recorded as percentage on the whole extension of examined area. The vascularization time was recorded as venous and arterial type. Imaging data were classified both concurrently with the examination and in a secondary blinded assessment; any difference in the subjective assessment was discussed and a consensus view formed. Pain and disability were assessed by Western Ontario McMaster Universities Arthritis Index (WOMAC) and EuroQuality of life 5-dimension-5-level questionnaire and visual analogue scale (EQ-VAS). All results were analysed with suitable statistical methods. RESULTS: 76.7% of cases were degenerated; 23.3% had also partial discontinuity of the fibres. PD detected vascularization in 54% of cases, whereas CEUS in 83% of cases: in 13 cases, PD did not detect vascularization. The vascularization time was rapid (< 20 s, arterial type) in 60% of cases. WOMAC pain mean value is 6.4 and SD 3.4; WOMAC total score mean value is 21.6 and SD 12.8. EQ-VAS mean value is 56 and SD 18.3. No statistically significant correlation emerged between vascularization and pain/disability. CONCLUSIONS: CEUS showed a greater ability to detect neovessels than PD in chronic Achilles tendinopathies. Nevertheless in 30 consecutive tendinopathies, no correlation between pain/disability and neovascularization was found: the role of multiple neovessels continue to be unclear. The possibility to discriminate arterial from venous vessels ('vascularization time') could be useful to understand the pathophysiology of tendinopathies and its healing process. STUDY TYPE: Diagnostic study. LEVEL OF EVIDENCE: II.

Urinary protein profiles in ketorolac-associated acute kidney injury in patients undergoing orthopedic day surgery.

BACKGROUND: Parenteral administration of ketorolac is very effective in controlling postoperative pain for orthopedic surgery. Ketorolac can induce clinically relevant renal alterations in elderly patients, whereas its short course is considered safe for young adults with normal preoperative renal function. In this study, of a cohort of young adults undergoing elective orthopedic day surgery, we sought cases complicated by readmission due to acute kidney injury (AKI). PATIENTS AND METHODS: Among 1397 young adults, aged 18-32 years who were admitted to undergo orthopedic day surgery from 2013 to 2015, four patients (0.29%, three males/one female) treated in postprocedure with ketorolac (from 60 to 90 mg/day for 1-2 days) were readmitted for suspected severe AKI. We evaluated functional outcome, urinary protein profiles and kidney biopsy (1 patient). RESULTS: After day surgery discharge, they experienced gastrointestinal disturbances, flank pain and fever. Readmitted on post-surgery days 3-4, they presented with oliguric AKI (creatinine range 158.4-466.4 µmol/L) and frank proteinuria (albumin range 2.1-6.0 g/L). Urine protein profiles demonstrated a nonselective glomerular proteinuria, with a significant 9.4-fold increase in glomerular/tubular index on day 6. Kidney biopsy on day 19 showed normal glomeruli and minimal tubular alterations and negative immunofluorescence. All patients recovered their renal function, and after 20 days proteinuria disappeared. CONCLUSION: AKI can ensue even in young adults who have undergone a short course of ketorolac, when they suffered from relative dehydration, abdominal disturbances, flank pain and oliguria after discharge. Urine findings were characterized by a marked nonselective glomerular proteinuria disappearing in 2-3 weeks.

The presence and influence of mild depressive symptoms on post-operative pain perception following primary total knee arthroplasty.

PURPOSE: To evaluate the influence of mild depression on pain perception after total knee arthroplasty (TKA). METHODS: Hamilton depression (HDRS) and numeric rating (NRS) scales were used to evaluate depression severity and pain perception at various intervals surrounding TKA. The Hospital for Special Surgery (HSS) knee and pain scores (NRS) in patients with signs of mild depression (HDRS < 20 points) were compared to a control group of patients with no signs of depression (HDRS < 8 points). RESULTS: Prior to surgery, there were no statistical differences in pain perception (NRS) or individual components of HSS knee score including range of motion, pain, and function between patients with mild depression compared to controls. However, following surgery, patients with signs of mild depression were more likely to report more pain (p < 0.001) and have lower HSS scores even at 1 year post-operatively (p < 0.001). CONCLUSIONS: A significant number of patients in this series undergoing routine primary TKA had signs of subclinical depression. These patients are more likely to report increased pain even at 1 year following surgery compared to patients without signs of depression preoperatively. Psychometric evaluation prior to surgery can help identify the at-risk patient and allow for proper management of patient expectations, thus improving clinical results and patients' satisfaction after TKA. LEVEL OF EVIDENCE: Prospective comparative study, II.

NexGen® LPS mobile bearing total knee arthroplasty: 10-year results.

PURPOSE: Mobile bearing (MB) knee prostheses were designed to improve the performances of the total knee arthroplasties (TKA). The clinical superiority of MB prosthesis compared to its fixed bearing counterpart has remained elusive. This study prospectively evaluates the cumulative survivorship, clinical, radiographic results, and complications of a large series of MB TKAs in relation to patient age, sex, severity of arthritis, and patellar resurfacing. METHODS: This study evaluates the 5- to 10-year cumulative survival rate of the NexGen(®) LPS MB. Between 2000 and 2005, we performed a consecutive series of 332 MB, posterior-stabilized TKA in 249 patients (mean age 71.2 years, SD 6.9). The implants were clinically evaluated with the Hospital Special Surgery Knee Score (HSS-KS) and radiographically with the Knee Society Roentgenographic Evaluation System (KS-RES). The mean follow-up was 76.3 months (minimum 5 years). RESULTS: The HSS-KS improved from 55 pre-operatively to 86 at the end of follow-up. According to the KS-RES, the implants were anatomically aligned and progressive radiolucent lines appeared in four knees (1.2 %). The patella was selectively resurfaced in 162 of 332 knees. Patients with the patella resurfaced had better clinical results compared to those not resurfaced, but there was no difference in terms of survival. The cumulative survival rate was 98.4 % at 10 years (Kaplan-Meier's analysis). CONCLUSIONS: This MB implant provided reliable and durable clinical results with a survivorship of over 98 % at 10 years, in unselected patients regardless of age, sex, severity of disease, and patellar treatment.

Incontinentia pigmenti: a rare pathology with complex rehabilitative aspects.

PURPOSE: Incontinentia pigmenti (IP), or Bloch-Sulzberger syndrome, is a rare X-linked dominant genetic disorder with multisystem involvement. To our knowledge, there are no previous reports about rehabilitation in IP adult with intact cognitive development. We report a 20-year-old lady with IP managed and followed into adulthood. METHOD: Patient management and rehabilitation programs from birth to the last follow-up. RESULTS: There was normal cognitive development despite magnetic resonance imaging (MRI) evidence of white matter, corpus callosum and brainstem hypoplasia. Extensor spasticity was present on both lower limbs for which she underwent rehabilitation from the age of one. Botulinum toxin injections were performed and when she was 15 years old she underwent functional surgery. CONCLUSION: The absence of mental retardation in our patient enabled us to carry out an active rehabilitation program and provide her with maximum independence in locomotion and in activities of daily living. IMPLICATIONS FOR REHABILIATION: Incontinentia pigmenti (Bloch-Sulzberger syndrome). Incontinentia pigmenti is a rare X-linked dominant genetic disorder with multisystemic involvement. Skin lesions, neurological impairments, motormental retardation, skeletal congenital defects and ophthalmologic involvement are IP most frequent manifestations. Due to the complex multisystem involvement resulting in severe long-term disability, patients with IP require a multidisciplinary team approach for rehabilitation. In IP patients, rehabilitation interventions should always take into consideration the individual phenotype expression, child's physical development and personal needs.

Endo-Modell rotating-hinge total knee for revision total knee arthroplasty.

The goal of this study was to analyze the clinical and radiographic results and the survival rate of a series of rotating-hinge implants used for revision total knee arthroplasties in mild and severe instability. Between December 1991 and June 2004, fifty-three revision total knee arthroplasties were performed using the Endo-Modell (Waldemar LINK GmbH and Co, Hamburg, Germany) rotating-hinge prosthesis; 7 (13.2%) patients underwent partial revision of a previous Endo-Modell. All patients were evaluated preoperatively, 3 and 6 months postoperatively, and annually thereafter using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation System (KS-RES). Mean follow-up was 155.2±40.1 months (range, 78-240 months), with 32 patients examined at the final follow-up. All HSS knee scores increased from preoperatively to last follow-up. No statistically significance differences were found in the HSS knee scores between septic and aseptic revisions and between total or partial revisions. Progressive radiolucent lines were detected in 8 (25%) patients. Implant failure occurred in 11 (20.7%) patients; the cumulative survival of the implants was 80.4% at 150 months for the final 32 patients. The authors recommend use of this implant for revision total knee arthroplasty, especially in patients with severe instability and bone loss.

Comparison of fixed and mobile-bearing total knee arthroplasty at a mean follow-up of 116 months.

BACKGROUND: The superiority of mobile-bearing total knee arthroplasty implants over fixed-bearing implants, or vice versa, is still debated. METHODS: A series of patients with similar clinical and radiographic characteristics were treated consecutively with 100 fixed-bearing followed by 100 rotating-platform implants. Patients underwent prospective clinical and radiographic evaluation. RESULTS: The mean duration of follow-up was 116 months (range, sixty-one to 144 months). Clinical, radiographic, and implant survival outcomes were compared. No significant differences between the mobile-bearing and fixed-bearing groups were found with respect to the clinical outcome or cumulative implant survival at the time of the latest follow-up. Three of the fixed-bearing implants and one of the rotating-platform implants had required revision surgery. CONCLUSIONS: No differences between mobile-bearing and fixed-bearing designs were demonstrated at a mean of 116 months of follow-up.

Results with 98 Endo-Modell rotating hinge prostheses for primary knee arthroplasty.

Rotating hinge knee prostheses have been developed as an advancement of the fixed hinge models. Some authors suggest that this type of prosthesis is associated with a greater risk of aseptic loosening because of the increased stresses to the bone-prosthesis interface; therefore, they are scarcely used as primary implants. The current authors evaluated of a series of 98 rotating hinge knee arthroplasties Endo-Modell (Waldemar LINK GmbH and Co, Hamburg, Germany) implanted for knee osteoarthritis. The Hospital for Special Surgery Knee Score and the Knee Society Score were used for the clinical and radiographic evaluation. Log-rank or Wilcoxon tests were used to test the statistical significances, and the Kaplan-Maier method was used to calculate the implant survival probability. After a medium follow-up of approximately 174 months, the clinical scores showed a statistically significant improvement from the pre- to postoperative period. The complication rate was high, and the cumulative implants survival rate was 88.7% at 1 year, 85.9% at 5 years, 79.8% at 10 years, and 75.8% at 15 years. The Endo-Modell rotating hinge implants demonstrated no significant risk of aseptic loosening, and the hinge was not a primary cause of failure. However, the overall failure rate was higher than that of unhinged implants; therefore, this prosthesis is recommended for cases of instability and revision rather than primary knee arthroplasty.

Rotating-hinge total knee for revision total knee arthroplasty.

Rotating-hinge knee implants are used for revision total knee arthroplasty in patients with severe ligament instability and bone loss. This study evaluated the outcomes of a series of rotating-hinge knees. Thirty-one NexGen Rotating Hinge Knees (Zimmer, Warsaw, Indiana) were implanted in 29 patients (2 bilateral), with an average age of 72.8 years. Indications for surgery were aseptic loosening (n=23), septic loosenings (n=4), tibiofemoral instability (n=3), and wear (n=1). The Hospital for Special Surgery Knee Score and the Knee Society Roentgenographic Evaluation System were used. Statistical and cumulative survival rate analyses were performed. Average follow-up was 60.3 months (range, 32-100 months). The Hospital for Special Surgery Knee Score results indicated statistically significant improvement; the total score increased from 65.5 preoperatively to 88.4 postoperatively. Average range of motion increased from 90.9° preoperatively to 114.4° postoperatively. Radiographs showed no periprosthetic bone fractures or implant ruptures. Radiolucent lines were found in 20 of 26 patients and were progressive in 2 (both revised). Complications occurred in 10 patients. The rigidity of the hinge may be associated with a risk of aseptic loosening due to the increased stress transfer to the bone from the prosthesis through the locked hinge. Rotating-hinge knee implants provided acceptable mid-term outcomes for revision knee surgery with ligamentous instability. They are not at higher risk for early loosening unless short tibial stems are used. The high percentage of failures is more related to the complex surgery and to the status of the patients than to the hinged mechanism.

Adult congenital permanent bilateral dislocation of the patella with full knee function: case report and literature review.

Congenital permanent dislocation of the patella is a rare disorder of the knee joint in which the patella is permanently displaced, even in extension and is fixed on the lateral aspect of the femoral condyle. The dislocation is irreducible without surgical techniques. This rare condition is usually detected within the first decade of life, because of inability of active extension in the knee and impaired ability during walking. This report presents an unusual case of a 51-year-old man with bilateral congenital permanent dislocation of the patella. The pathology had never been treated because there were few symptoms. The patient presented with right knee pain caused by a fall on the knee during his work. The right knee was painful on the lateral side and the clinical signs were positive for pathology of the lateral meniscus, confirmed by MRI. The clinical and the imaging findings suggested a lesion of the lateral meniscus as the probable cause of the pain. Therefore we performed a knee arthroscopy, whose intra-operative findings confirmed the MRI findings. During the surgery we performed just a selective arthroscopic meniscectomy, without correcting patella dislocation, because the condition was unusually asymptomatic before the trauma.

Modular cementless cup for total hip arthroplasty: results at 4-year follow-up.

The aim is to perform the assessment of a modular cementless acetabular cup with a tapered internal design for all bearing couplings. In 190 unselected consecutive patients, 207 total hip arthroplasties were implanted. The implants were clinically and radiographically evaluated. Follow-up was 49.7 ± 8.1 months. The average Harris hip score improved from 55.5 ± 5.7 to 94.7 ± 3.4 (P < 0.05). All cups were well-positioned and stable. The Kaplan-Maier cumulative survivorship was 98.5 ± 0.8%. No significant differences have been noted in dividing patients according to the different liner materials (P < 0.005). The study, whose rationale is the novelty of this kind of implant, suggests the efficacy of the Delta-PF acetabular cup.

Arthroscopic treatment of hip chondral defects: autologous chondrocyte transplantation versus simple debridement--a pilot study.

PURPOSE: To compare the effectiveness of simple arthroscopic debridement versus arthroscopic autologous chondrocyte transplantation (ACT) for the treatment of hip chondral lesions. METHODS: We carried out a controlled retrospective study of 30 patients affected by a post-traumatic hip chondropathy of the third or fourth degree, according to the Outerbridge classification, measuring 2 cm² in area or more. Of these patients, 15 underwent arthroscopic ACT, whereas the other 15 underwent arthroscopic debridement. The 2 groups were similar in age, sex, degree, and location of the pathology. All the patients were assessed before and after the procedure with the Harris Hip Score (HHS). RESULTS: In both groups the mean follow-up was approximately 74 months (range, 72 to 76 months). The mean size of the defect was 2.6 cm². The patients who underwent ACT (group A) improved after the procedure compared with the group that underwent debridement alone (group B). The mean HHS preoperatively was 48.3 (95% confidence interval [CI], 45.4 to 51.2) in group A and 46 (95% CI, 42.7 to 49.3) in group B (P = .428 [no significant difference]). The final HHS was 87.4 (95% CI, 84.3 to 90.5) in group A and 56.3 (95% CI, 54.4 to 58.7) in group B (P < .001 [significant difference]). CONCLUSIONS: This study indicates that an ACT procedure can be used in the hip for acetabular chondral defects. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Dislocation rate after hip arthroplasty within the first postoperative year: 36 mm versus 28 mm femoral heads.

Dislocation is a common and important complication of total hip arthroplasty (THA). Larger femoral heads may reduce the risk of dislocation and improve the range of movement. The aim of this study was to compare the relative risk (RR) of dislocation during the first year after THA between implants with 28 mm and 36 mm femoral heads. 198 consecutive hips with 28 mm femoral head (Group-28) and 259 hips with 36 mm femoral head (Group-36) were studied. The patients were assessed preoperatively and periodically using the Harris hip score (HHS) and radiographic analysis. The relative risk (RR) of dislocation was calculated. The average HHS significantly improved from a preoperative baseline to the last follow-up at 82.1 months (28 mm) and 44.3 months (36 mm). No statistically significant differences were revealed between the two groups for HHS results and complications (p>0.05), but the difference in RR of dislocation within the first year between the two groups was 7.85 (95% CI: 1.34-46.03), p=0.046.Although dislocation is multifactorial in etiology, the two groups were homogenous for all principal contributing factors except the diameter of the femoral head. Therefore, the use of 36-mm heads can reduce the risk of dislocation following THA by a factor of 8 compared to conventional 28 mm heads.

Operative Management of Sciatic Nerve Palsy due to Impingement on the Metal Cage after Total Hip Revision: Case Report.

This paper discusses a sciatic nerve palsy developed after a right total hip revision with a Burch-Schneider metal cage. A sciatalgic nerve pain appeared after surgery, while the palsy developed in about fifteen days. An electromyography showed the delay of the nerve impulse gluteal level. During the surgical exploration of the hip, a compression of the nerve on the metal cage was observed. The nerve was isolated, released from the fibrotic tissue and from the impingement, and was protected with a muscular flap. The recover from the pain was immediate, while the palsy recovered one month later.