Effect of Preoperative Nutritional Status on Postoperative Functional Recovery of Hip Joint in Elderly Patients with Intertrochanteric Fractures.

Objective: The state of nutrition of senior patients with intertrochanteric fracture of femur before operation affects the patients' tolerance to the operation,the body recovery, healing of the wound and clinical prognosis. For these patients, the poor state of nutrition may lengthen the time of being in hospital, leading to poor hip recovery and clinical outcome. But currently, the relationship between functional recovery of hip joint after operation of intertrochanteric fracture in elderly patients and camp condition has not been reported. To investigate the effect of preoperative nutritional status on postoperative recovery of hip joint function in elderly patients with intertrochanteric fractures. Methods: Retrospective analysis was performed on the data of 96 elderly patients with intertrochanteric fracture of the femur treated with closed reduction PFNAfrom January 2021 to January 2022 in Dongying People's Hospital Trauma Orthopedics Department. There were 36 male patients and 60 female patients aged from 65 to 92.The patients were divided into the normal nutrition group (GNRI ≥ 92, n = 46) and the malnutrition group (GNRI < 92, n = 50). The general clinical data, time from injury to operation, intraoperative and postoperative allogeneic blood transfusion rate, postoperative complication rate, postoperative mortality 1 year, and Harris hip function score at 3, 6, 9 months and the last follow-up were compared between the two groups. Results: All patients were followed up for 9 to 15 months(mean,13.9 months) after surgery. The preoperative hemoglobin levels in the normal and malnutrition groups were 8.6-13.2 and 7.4-11.2 g/dL, respectively (P < .05). The time from injury to surgery in the normal nutrition group was significantly shorter than that in the malnutrition group (P < .01). The preoperative hemoglobin level in the normal nutrition group was significantly higher than that in the malnutrition group. The time from injury to operation in normal nutrition group and malnutrition group are respectively (1.1-5.2), (4.3-6.6)d; the intraoperative and postoperative allogeneic blood transfusion rates are respectively 47.8%(22/46), 92%(46/50);the incidence of postoperative complications are respectively 6.52%(3/46), 32%(16/50); the mortality rates within 1 year after operation are respectively 2.17%(1/46), 12%(6/50). In contrast, the postoperative allogeneic blood transfusion, postoperative complication, and postoperative complication rates in the normal nutrition group were significantly lower than those in the malnutrition group (P < .05). 3 months after surgery, the Harris hip function scores of patients in normal nutrition group and malnutrition group are respectively (75.26±4.02), (64.28±3.82); 6 months after surgery, the Harris hip function scores of them are respectively (80.42±3.86), (70.14±5.06).During the last follow-up, scores are (82.23±2.98), (72.12±4.62). At the 3, 6, and last follow-up after surgery, the Harris hip function score in the normal nutrition group was significantly higher than in the malnutrition group (P < .05). Conclusion: Preoperative malnutrition in elderly patients with intertrochanteric fracture has adverse effects on postoperative hip function recovery, and 1-year postoperative survival rate.GNRI can be used for simple screening. Early assessment of patients' nutritional status.

The effectiveness of hydrotherapy on return to play in sports following hip arthroscopic surgery: a comparative study.

BACKGROUND: The postoperative management of femoroacetabular impingement (FAI) is variable with favourable surgical outcomes. Yet there is no evidence on the efficacy of hydrotherapy in athletes undergoing hip arthroscopy for FAI. The purpose of this study was to evaluate the role and the impact of hydrotherapy on return to sports following hip arthroscopy for symptomatic FAI. METHODS: 2 cohorts of mixed level of athletes from various sports: a hydrotherapy group that followed land-based exercises in combination with hydrotherapy exercises and a control group that followed solely the same land-based exercises. Pre- and postoperative pain and hip-specific outcome scores were completed, and patient satisfaction was rated. RESULTS: A total of 88 hip arthroscopies were included with a minimum of 2 years follow-up; the hydrotherapy group comprised of 36 hips and the control group, 52 hips. There was a significant improvement in time to return to previous performance (HR 1.91, 95% CI, 1.21-3.01; p = 0.005) in the hydrotherapy group compared with the control. The hip-specific scores and patient satisfaction were considerably improved in the hydrotherapy group. CONCLUSIONS: The analysis of our data indicates that the incorporation of hydrotherapy into postoperative rehabilitation for hip arthroscopy for FAI accelerates the return of athletes to their pre-injury performance, since recovery time decreased significantly.

A novel hip joint prosthesis with uni-directional articulations for reduced wear.

A novel polymer-on-metal hip joint prosthesis design that makes use of uni-directional articulations was developed and tested in this work. The new implant was tested using two polymer variants, virgin ultra-high molecular weight polyethylene (UHMWPE), and Vitamin E-infused highly crosslinked polyethylene (VEHXPE). The degrees of freedom of the ball-and-socket are reproduced by three cylindrical orthogonally-aligned articulations. This unconventional design leverages on the molecular orientation hardening mechanisms of the polyethylene and increased contact area to minimize wear. An experimental hip joint simulator was used to compare the gravimetric wear of the conventional ball-on-socket and the new implant. The new prosthesis including UHMWPE components produced a 78% reduction in wear, whereas the new prosthesis with VEHXPE components produced a 100% reduction in wear, as no measurable wear was detected. Machining marks on the acetabular cups of the new prosthesis were retained for both polyethylene variants, further demonstrating the low levels of wear exhibited by the new implants. Both polyethylene materials produced particles in the range of 0.1-1.0 µm, which are the most biologically active. Nonetheless, the extremely low wear rates are likely to induce minimal osteolysis effects. Furthermore, the novel design also offers an increase of more than 24% in the range of motion in flexion/extension when compared to a dual-mobility hip implant. A prototype of the prosthesis was implanted into a Thiel-embalmed human cadaver during a mock-surgery, which demonstrated high resistance to dislocation and the possibility of performing a figure of four position.

Long-Term Results of Alumina Ceramic-On-Ceramic Bearings in Cementless Total Hip Arthroplasty: A 20-Year Minimum Follow-Up.

BACKGROUND: Alumina ceramic-on-ceramic bearings are used in total hip arthroplasty (THA) because of their wear-resistant and inert properties. In this study, we assessed the clinical and radiographic outcomes of patients undergoing primary cementless ceramic-on-ceramic THA at a minimum follow-up of 20 years. METHODS: A series of 301 consecutive primary THAs in 283 patients were assessed. Clinically, patients were assessed with the modified Harris Hip Score (HHS) and pain questionnaires. Anteroposterior radiographs of the pelvis and lateral radiographs of the hip were used to radiologically assess the implant. Patients were classified as lost to follow-up if they could not be contacted on multiple occasions or did not wish to participate further in this study. RESULTS: At twenty years after operation, 60 patients had died of a cause unrelated to surgery, 16 had experienced complications requiring reoperation, and 100 hips had both clinical assessments and radiographs at a minimum of 20 years of follow-up. The average HHS improved from 56.1 (range: 17-89) before THA to 92.5 (range: 63-100) at the latest follow-up. The classification of the HHS was good or excellent in 96.4% of patients. Only 1.8% of patients still had moderate residual pain at the thigh or groin. Radiographically, all patients demonstrated bony ingrowth but no clinical symptoms of loosening. The overall survival rate of the implants was 94.2% at 20 years with revision for any reason as the end point. CONCLUSION: Long-Term follow-up in our series showed excellent implant survival, excellent functional outcomes, and minimal late complications. There was no significant radiographic evidence of failure at a minimum of 20 years after THA. LEVEL OF EVIDENCE: Therapeutic Level IV.

Uncemented total hip arthroplasty using alumina ceramic bearings at a minimum of 14 years of follow-up.

INTRODUCTION: The effectiveness of modern ceramic bearings has been well established in reducing the osteolysis associated with wear of the bearing surfaces in total hip arthroplasty (THA). However, there are limited mid- to long-term follow-up data for complications associated with ceramic bearings. MATERIALS AND METHODS: This case series analyzed 124 consecutive primary uncemented THAs in 108 patients with a mean age of 61 years using alumina ceramic-on-alumina ceramic bearing couples. Seventy THAs (56%) were evaluated at a minimum 14 years of follow-up; the mean follow-up period was 16 ± 1 years (14-20 years). Kaplan-Meier survivorship was determined with revision surgery for any reason as the end point. Complications were recorded focusing on osteolysis, ceramic fracture, and abnormal sounds until the final follow-up. Clinical data were scored according to the Merle d'Aubigne and Postel hip score at 14 years after THA. RESULTS: The survivorship was 93.5% (95% CI 86.7-97.0%) at 14-years postoperatively. Five patients (4.0%) underwent revision surgery due to instability or infection before 1-year postoperatively. Two patients (1.6%) underwent revision surgery due to ceramic liner fracture at 9- and 12-years postoperatively, respectively. There was no radiographic evidence of osteolysis. A total of 27 complications occurred: dislocations (n = 7/124), squeaking sounds (n = 3/124), clicking sounds (n = 6/124), ceramic liner fractures (n = 2/124), periprosthetic fractures (n = 4/124), deep infections (n = 2/124), transient sciatic nerve palsy (n = 2/124), and femoral stem breakage (n = 1/124). The Merle d'Aubigne and Postel hip score was 16.8 ± 1.4 points. CONCLUSIONS: The survivorship analysis demonstrates the uncemented THA using alumina ceramic bearings may provide favorable clinical outcome and can offer minimal wear at a minimum 14-year follow-up. Revision surgery was mostly required due to instability and infection in the short-term, and implant breakage in the mid- to long-term.

Utilization of Physical Therapy Prior to Consultation for Hip Preservation Surgery.

Background: Comprehensive conservative care prior to arthroscopic hip surgery is recommended, but not all patients pursue a course of physical therapy (PT) prior to consulting a hip surgeon. The purpose of this study is to investigate the incidence and type of PT administered to patients with hip pain prior to consulting a hip surgeon. Methods: We conducted a single-center, questionnaire-driven study at a young adult hip preservation clinic that exclusively treats patients with hip pain. Thirty (88%) of thirty-four consecutive new patients answered the 15-item questionnaire. The questionnaire was designed to inquire about the reason for the visit, type of formal PT received (hip strengthening, leg strengthening etc.), and additional treatments received prior to the visit (electric stimulation, narcotics etc.). Descriptive statistics were utilized to quantify the reason for visit, PT prior to the visit, and type of exercises performed during physical therapy. Results: Overall, 21 (70%) patients received physical therapy prior to consulting with a hip surgeon. Of those who received PT, 91% (n=19) did hip strengthening exercises, 76% (n=16) did focused hip stretching exercises, 62% (n=13) did leg strengthening exercises, 57% (n=12) did joint mobilization exercises, and 52% (n=11) did focused core strengthening exercises. Only 48% (n=10) reported improvement in symptoms with PT. Of those who received additional treatments, 77% (n=20) took anti-inflammatory medications regularly, 50% (n=13) underwent electric stimulation, 31% (n=8) had chiropractic manipulation, 19% (n=5) underwent soft tissue mobilization, 15% (n=4) received steroid injections, and 12% (n=3) were prescribed narcotics for hip pain. Conclusion: The present study offers insight into the incidence and type of formal PT patients with hip pain receive before consulting a hip surgeon. Treatment methods during PT visits are variable, which makes determining outcomes of conservative care difficult to assess in this population.Level of Evidence: IV.

Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique.

BACKGROUND: Greater trochanteric pain syndrome encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and lateral snapping hip (LSH). Surgical options for LSH range from open surgery to endoscopic surgery, including a diamond-shaped cut or a simple transversal release to gluteus maximus tendon release. Resection of an area of proximal iliotibial band (ITB) and step-cut or z-plasty lengthening have not proven superior to transverse release of the ITB. Therefore, making a complete and effective transverse cut guided by ultrasound may represent a potential advance over endoscopic surgery. PURPOSE: In this case series study, we describe how to perform proximal release of the ITB guided by ultrasound. METHODS: The surgical technique-either z-plasty or transverse section of the ITB-was first validated on 10 cadaver specimens and then used in clinical practice. Fourteen patients (5 males and 9 females) were operated from 2014 to 2018. Mean age was 43 years (29-62). RESULTS: The snap resolved in all patients, as verified actively during the surgical procedure as the patient has only local anesthesia. The VAS score for sports activity improved from 7 (5-9) before surgery to 0 (0-2) after 1 year. The HSS score improved from 58 points (47-72) to 96 at 1-2 years. There were no complications other than minor hematomas nor recurrences. CONCLUSION: Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. It can be performed under local anesthesia in an outpatient setting with minimal aggressiveness. It is relatively easy, quick, and painless; no stitches are required. Weight bearing is immediate, and patients usually need crutches for only 2-3 days. Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless.

The effect of traditional Chinese medicine fumigation and washing as a complementary and alternative therapy on the recovery of joint function after development dysplasia of the hip in children: A protocol for systematic review and meta-analysis.

BACKGROUND: Development dysplasia of the hip (DDH) is a common childhood orthopedic disease in clinic. The cause of DDH is not yet clear. If DDH is not treated promptly or correctly, it will seriously affect the life quality of the child. At present, surgery is the main means of treating older DDH, but it is easy to appear development dysplasia of the hip after surgery, and the joint movement is limited after surgery. For modern medicine, it has not many treatments to solve this problem. As one of the commonly used treatment methods, but the effect of routine functional exercise is not ideal. Traditional Chinese medicine fumigation and washing belongs to the category of Chinese medicine external treatment, which can directly act on the focus. It has the functions of relaxing muscles and tendons and removing obstruction from meridians, activating blood to eliminate stagnation. It has achieved good effects in relieving joint disorders, but it is lack of the high-quality evidence support, so there is controversy about the clinical application of traditional Chinese medicine fumigation and washing. This study will conduct a systematic review to compare the application effect and safety of traditional Chinese medicine fumigation and washing as a complementary and alternative therapy and traditional rehabilitation training in the treatment of postoperative joint function recovery after development dysplasia of the hip in children. The research results will provide evidence-based medical evidence to support the choice of treatment for the disease. METHODS: Using computer to retrieve PubMed, ScienceDirect, Web of Science, EMBase, Cochrane Library, WANFANG Database, CNKI, and VIP Database, CBM, and using the method of combining mesh words with item words to retrieve the Chinese and English databases, to retrieve the randomized controlled study on the application of traditional Chinese medicine fumigation and washing on the recovery of joint function after development dysplasia of the hip in children. The retrieval time is from January 1990 to January 2021. Two researchers screen and evaluate the quality of the retrieved literatures according to the inclusion and exclusion criteria. In the event of a disagreement, a third researcher will join the discussion to resolve the disagreement. Using Revman 5.3 software to conduct meta-analysis. RESULTS: This study will compare the application effect and safety of traditional Chinese medicine fumigation and washing as a complementary and alternative therapy and traditional rehabilitation training in the treatment of postoperative joint function recovery after development dysplasia of the hip in children. CONCLUSION: The results of this study will be published in an internationally influential academic journal to provide evidence-based medical evidence for the selection of supplement and alternative therapies on the recovery of joint function after development dysplasia of the hip in children. ETHICS AND DISSEMINATION: This study does not involve specific patients, and all research data comes from publicly available professional literature, so an ethics committee is not required to conduct an ethical review and approval of this study. OSF REGISTRATION: DOI 10.17605/OSF.IO/RUHK5.

Does the Capital Femoral Physis Bony MorphologyDiffer in Children with Symptomatic Cam-type Femoroacetabular Impingement.

BACKGROUND: The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology. QUESTIONS/PURPOSES: (1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls? METHODS: After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI. RESULTS: After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side. CONCLUSION: Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning. LEVEL OF EVIDENCE: Level III, prognostic study.

High-level judo practice after hip resurfacing.

BACKGROUND AND HYPOTHESIS: The ability to participate in sports after hip arthroplasty is increasingly being requested by patients. The possibilities of participating in sports such as judo after hip arthroplasty have not been explored sufficiently even though these sports are associated with a high risk of loosening, dislocation or revision. The aim of this study was to evaluate the return to judo after hip resurfacing arthroplasty (HRA) in terms of time and level of practice in an expert population and to determine the surgical complication rate. MATERIALS AND METHODS: This was a retrospective observational study of all licensed judo practitioners at an expert level (≥black belt 3rd Dan) who underwent HRA. Patients filled out a sport-specific questionnaire that captured their level of judo practice (international, national, regional, recreational), type of practice (teaching, technical recreational, competitive recreational), dan grade, weekly volume of practice and time elapsed after surgery before resuming judo. The features of the return to judo were analyzed (technical, ground, combat). RESULTS: Sixty-seven HRA were implanted in 60 patients: 11 were international judokas, 3 were national, 8 were regional and 38 were recreational. The case series consisted of 18 patients who were 3rd Dan, 18 were 4th Dan, 7 were 5th Dan, 5 were 6th Dan and 12 were 7th Dan. The average follow-up was 65.3 months (range 9.9-11.9). All the clinical scores pointed to clinically and statistically significant improvement. Of the 60 patients, 53 had resumed judo at the final assessment (90%) after a mean of 4 months (2-7) for technical judo, 6 months (3-10) for ground judo and 7 months (3-12) for combat judo. Of those who did not resume their judo practice, 3 patients voluntarily changed sports, 2 had psychological apprehension and 2 had residual groin pain. The weekly volume of practice preoperatively was 0.9hours (0-5) and postoperatively it reached 5hours (2-18) (P<0.001). CONCLUSION: HRA in a population of high-level judokas allows for return to sport practice without short-term complications such as fracture, dislocation or loosening. LEVEL OF EVIDENCE: III.

Surgical strategies in management of ankylosed bilateral hips and knees in crouched posture.

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up.

Experimental design of Al2O3/MWCNT/HDPE hybrid nanocomposites for hip joint replacement.

Fracture in the hip joint is a major and quite common health issue, particularly for the elderly. The loads exploited by the lower limbs are very acute and severe; in the femur, they can be several folds higher than the whole weight of the body. Nanotechnology and nanocomposites offer great potential in biomedical applications. The organic materials are more biocompatible. Mechanical properties like strength and hardness are challenging parameters which control the selection of a joint. HDPE in its pure form has been successfully used as a prosthetic foot (external) but failed as an implant material due to limited mechanical properties. High-density polyethylene thermoplastic polymer (HDPE) and multi-walled carbon nanotubes (MWCNT)/Nano-Alumina is selected as a potential material for a biomedical implant and its mechanical properties and biocompatibility have been discussed. HDPE/MWCNT/Alumina (Al2O3) nanocomposites have not been explored yet for prosthetic implants. These nanocomposites were prepared in this investigation in different compositions. Prepared material has been physiochemically characterized to check the morphology and the structure. MWCNTs enhanced hardness and elastic modulus of the HDPE. Optimization of the material composition revealed that hybrid composite with structure (2.4% Al2O3 and 0.6% MWCNT) exhibits better mechanical properties compared to other ratios with 3% MWCNTs and 5% MWCNTs. Thermal gravimetric analysis (TGA) dedicates that the percentage of crystallization has been increased to 6% after adding MWCNT to HDPE. The moisture absorption decreased to 90% with 5% MWCNT. Experimental results of Colorimetric assay (MTT) of a normal human epithelial cell line (1- BJ1) over Al2O3/MWCNT@HDPE showed <20% cytotoxic activity, proving its acceptance for medical use. HDPE/MWCNT/Al2O3 nanocomposites emerged as a candidate material for artificial joints.

Treatment strategies for ischiofemoral impingement: a systematic review.

PURPOSE: There has been relatively little information about the treatment for ischiofemoral impingement (IFI) because of its rarity as well as the uncertainty of diagnosis. The aim of this study was to provide the reader with the available treatment strategies and their related outcomes for IFI based on the best available evidence, whilst highlighting classically accepted ways of treatment as well as relatively new surgical and non-surgical techniques. METHODS: A systematic review of the literature from Medline, Embase, AMED, Cochrane and Google Scholar was undertaken since inception to December 2017 following the PRISMA guidelines. Clinical outcome studies, prospective/retrospective case series and case reports that described the treatment outcome for IFI were included. Animal or cadaveric studies, trial protocols, diagnostic studies without any description of treatments, technical notes without any results, and review articles were excluded. RESULTS: This systematic review found 17 relevant papers. No comparative studies were included in the final records for qualitative assessment, which means all the studies were case series and case reports. Eight studies (47.1%) utilised non-surgical treatment including injection and prolotherapy, followed by endoscopic surgery (5 studies, 29.4%) then open surgery (4 studies, 23.5%). Mean age of the participants was 41 years (11-72 years). The mean follow-up was 8.4 months distributed from 2 weeks to 2.3 years. No complications or adverse effects were found from the systematic review. CONCLUSION: Several treatment strategies have been reported for IFI, and most of them have good short- to medium-term outcomes with a low rate of complications. However, there are no comparative studies to assess the superiority of one technique over another, thus further research with randomised controlled trials is required in this arena. This study explores the wide variety and categories of different treatments used for IFI to guide physicians and shed light on what can be done for this challenging cohort of patients. LEVEL OF EVIDENCE: III.

Short and mid-term outcomes and functional results in metal-on-metal hip resurfacing arthroplasty at 5 years follow-up: the Spanish experience.

BACKGROUND: Hip resurfacing arthroplasty (HRA) and in particular, Birmingham hip resurfacing (BHR), is commonly employed as an alternative to total hip arthroplasty (THA) in young patients, as it allows for preservation of femoral bone stock and resumption of physical activity. The aim of our study was to investigate 5-year survival and functional outcomes of BHR arthroplasty in young Spanish osteoarthritis (OA) patients. METHODS: This is an observational, prospective, cohort study of patients who underwent BHR between June 2005 and December 2009 at a Spanish public hospital with a minimum follow-up of 5 years. All surgeries were performed by a single surgeon (RLM). Survival was analyzed using the Kaplan-Meier method. Functional outcomes and return to work and physical activities were also assessed. RESULTS: Five-year survival rate of the prosthesis was 95.74% (95% CI: 95.77-98.07), and estimated 10-year survival was 92.92% (95% CI: 85.07-96.72). Harris hip score significantly increased from 41.13 to 97.63 (p < 0.001) at 5-year follow-up. Average time for returning to work and sporting activities was 3.89 (SD: 2.39) and 3.47 (SD: 1.18) months respectively. Failure occurred in 14 patients, 8 of whom experienced femoral neck fractures. CONCLUSIONS: Our data support the short and mid-term efficacy of BHR arthroplasty in young OA patients, indicating good implant survival, improvement in patients' functionality and a swift return to work and physical activities after surgery.

Results of 200 Consecutive Ceramic-on-Ceramic Cementless Hip Arthroplasties in Patients Up To 50 Years of Age: A 5-24 Years of Follow-Up Study.

BACKGROUND: Ceramic-on-ceramic (CoC) bearings due to their mechanical properties can be used in primary total hip arthroplasty (THA) especially in young patients requiring a long-lasting implant. The goal of this study is to analyze the results of a series of 200 consecutive CoC THAs in patients aged 50 years or less at the time of surgery. METHODS: A retrospective study was conducted on the first 200 consecutive CoC arthroplasties performed using the direct lateral approach on 105 females and 81 males (14 bilateral cases) with an average age of 44.2 (16-50) years. The diagnosis was primary or post-traumatic osteoarthritis in 94 cases, avascular necrosis of the femoral head in 47, displaced intracapsular femoral neck fracture in 29, osteoarthritis secondary to developmental dysplasia of the hip/Legg-Calvè-Perthes disease/slipped capital femoral epiphysis in 20, and rheumatic diseases in 10 cases. The preoperative Harris Hip Score was 32.5 on average (range 15-55). All the implants were cementless. In 177 THAs the coupling was alumina-on-alumina, and in 23 cases the coupling was AMC-on-AMC (alumina matrix composite). RESULTS: Twenty-five patients with 28 THAs were lost at the final follow-up, 2 stems were revised due to subsidence, 1 cup was revised due to malposition, 1 femoral head was changed because of impingement, and 1 THA was revised for periprosthetic infection. Three patients sustained a Vancouver B1 periprosthetic femoral fracture. At the final follow-up (mean 14.9 years; minimum 5 years to maximum 24 years), 172 THAs were eligible for clinical and radiographic evaluation: none was revised for wear and/or breakage of the ceramic components. Harris Hip Score rose up to a mean value of 90.1 (52-100). CONCLUSION: The present report demonstrates that CoC coupling offers excellent long-term results in THA performed in young patients with very low wear and no adverse effects caused by the material.

A randomized, double-blind, placebo-controlled trial on the efficacy of tranexamic acid combined with rivaroxaban thromboprophylaxis in reducing blood loss after primary cementless total hip arthroplasty.

AIMS: Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. PATIENTS AND METHODS: A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. RESULTS: TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). CONCLUSION: In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis.

Interplay between sympathetic nervous system and inflammation in aseptic loosening of hip joint replacement.

Inflammation is a common symptom in joint disorders such as rheumatoid arthritis, osteoarthritis (OA) and implant aseptic loosening (AL). The sympathetic nervous system is well known to play a critical role in regulating inflammatory conditions, and imbalanced sympathetic activity has been observed in rheumatoid arthritis. In AL it is not clear whether the sympathetic nervous system is altered. In this study we evaluated the systemic and local profile of neuroimmune molecules involved in the interplay between the sympathetic nervous system and the periprosthetic inflammation in hip AL. Our results showed that periprosthetic inflammation does not trigger a systemic response of the sympathetic nervous system, but is mirrored rather by the impairment of the sympathetic activity locally in the hip joint. Moreover, macrophages were identified as key players in the local regulation of inflammation by the sympathetic nervous system in a process that is implant debris-dependent and entails the reduction of both adrenergic and Neuropetide Y (NPY)-ergic activity. Additionally, our results showed a downregulation of semaphorin 3A (SEMA3A) that may be part of the mechanism sustaining the periprosthetic inflammation. Overall, the local sympathetic nervous system emerges as a putative target to mitigate the inflammatory response to debris release and extending the lifespan of orthopedic implants.

What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review.

Nutritional supplements can influence outcomes for individuals undergoing major surgery, particularly in older persons whose functional reserve is limited. Accelerating recovery from total hip replacement (THR) and total knee replacement (TKR) may offer significant benefits. Therefore, we explored the role of nutritional supplements in improving recovery following THR and TKR. A systematic review was conducted to source randomized clinical trials that tested nutritional supplements in cohorts of THR or TKR patients. Our search yielded nine relevant trials. Intake of a carbohydrate-containing fluid is reported to improve insulin-like growth factor levels, reduce hunger, nausea, and length of stay, and attenuate the decrease in whole-body insulin sensitivity and endogenous glucose release. Amino acid supplementation is reported to reduce muscle atrophy and accelerate return of functional mobility. One paper reported a suppressive effect of beta-hydroxy beta-methylbutyrate, L-arginine, and L-glutamine supplementation on muscle strength loss following TKR. There is limited evidence for nutritional supplementation in THR and TKR pathways; however, the low risk profile and potential benefits to adjunctive treatment methods, such as exercise programs, suggest nutritional supplements may have a role. Optimizing nutritional status pre-operatively may help manage the surgical stress response, with a particular benefit for undernourished, frail, or elderly individuals.

Outcomes of cartilage repair techniques for chondral injury in the hip-a systematic review.

OBJECTIVE/PURPOSE: The aim of the study was to assess the options of treatment and their related outcomes for chondral injuries in the hip based on the available evidence whilst highlighting new and innovative techniques. METHODS: A systematic review of the literature from PubMed (Medline), EMBASE, Google Scholar, British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine Database (AMED) was undertaken from their inception to March 2017 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Clinical outcome studies, prospective/retrospective case series and case reports that described the outcome of cartilage repair technique for the chondral injury in the hip were included. Studies on total hip replacement, animal studies, basic studies, trial protocols and review articles were excluded. RESULTS: The systematic review found 21 relevant papers with 596 hips. Over 80% of the included studies were published in or after 2010. Most studies were case series or case reports (18 studies, 85.7%). Arthroscopy was used in 11 studies (52.4%). The minimum follow-up period was six months. Mean age of the participants was 37.2 years; 93.5% of patients had cartilage injuries of the acetabulum and 6.5% of them had injuries of the femoral head. Amongst the 11 techniques described in the systematic review, autologous matrix-induced chondrogenesis, osteochondral autograft transplantation and microfracture were the three frequently reported techniques. CONCLUSION: Over ten different techniques are available for cartilage repair in the hip, and most of them have good short- to medium-term outcomes. However, there are no robust comparative studies to assess superiority of one technique over another, and further research is required in this arena.

Regenerative therapies increase survivorship of avascular necrosis of the femoral head: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to document the available evidence on the use of regenerative techniques for the treatment of femoral head osteonecrosis (or avascular necrosis of femoral head, AVN) and to understand their benefit compared to core decompression (CD) alone in avoiding failure and the need for total hip replacement (THR). METHODS: The search was conducted on three medical electronic databases according to PRISMA guidelines. The studies reporting number and timing of failures were included in a meta-analysis calculating cumulative survivorship with a Kaplan-Mayer curve. Moreover, the results on failures in treatment groups reported in RCT were compared with those documented in control groups, in order to understand the benefit of biological therapies compared to CD for the treatment of AVN. RESULTS: Forty-eight studies were included in this systematic review, reporting results of different types of regenerative techniques: mesenchymal stem cell implantation in the osteonecrotic area, intra-arterial infiltration with mesenchymal stem cells, implantation of bioactive molecules, or platelet-rich plasma. Overall, reported results were good, with a cumulative survivorship of 80% after ten year follow-up, and better results when regenerative treatments were combined to CD compared to CD alone (89.9% vs 70.6%, p < 0.0001). CONCLUSION: Regenerative therapies offer good clinical results for the treatment of AVN. The combination of CD with regenerative techniques provides a significant improvement in terms of survivorship over time compared with CD alone. Further studies are needed to identify the best procedure and the most suitable patients to benefit from regenerative treatments for AVN.