Recent advances in the direct anterior approach to total hip arthroplasty: a surgeon's perspective.

INTRODUCTION: The direct anterior approach (DAA) has its origins in the first and oldest approach for hip replacement in the literature, but at the same time it would not be fanciful to suggest its increasing popularity as the latest approach for hip replacement procedures, especially among younger surgeons. However, in a geographical context, the DAA is not considered the major approach in most countries. Moreover, the term DAA encompasses numerous variations in terms of technique. AREAS COVERED: In this narrative review, we describe our recent experience of advances in the DAA in terms of improved techniques and devices, along with some of its disadvantages. Also, we express our perspective on its future application. EXPERT OPINIONS: The DAA is established as one of exemplary approaches to THA. The use of fluoroscopy, the traction table, and appropriate soft tissue management has become essential in the DAA for a safe and trouble-free procedure with adequate patient comfort. With the combination of recent technologies such as robotics, three-dimensional preoperative planning, and artificial intelligence (AI)-based surgeon assist systems, we can look forward to the DAA being performed more efficiently in the future.

Conventional versus lateral fasciotomy for prevention of lateral femoral cutaneous nerve injury in the non-fan-type nerve in total hip arthroplasty with direct anterior approach.

Aims: Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods: In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results: The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion: The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches.

A Case Report of Burning Mouth Syndrome with Dry Mouth Managed by Kampo Medicine.

The patient was a 56-year-old woman who complained of chronic pain involving her tongue. We diagnosed her with burning mouth syndrome (BMS) based on exclusion of any local factors or systemic conditions. The patient not only had tongue pain but also had other signs and symptoms like scalloped tongue, dry mouth, and headache. To manage these additional issues, we used Goreisan, an herbal Kampo medicine, as a complementary alternative medicine (CAM) approach along with cognitive behavioral therapy (CBT). The patient's BMS was successfully managed with the combination of CAM and CBT, which may suggest that the pathophysiology for BMS might be nociplastic pain rather than purely nociceptive or neuropathic.

Immune-related adverse events in urothelial cancer patients: Adjustment for immortal time bias.

To investigate the association between the onset, severity, and type of immune-related adverse events (irAEs) and the efficacy of pembrolizumab in patients with platinum-pretreated advanced urothelial carcinoma (UC), we retrospectively collected clinical datasets of 755 patients and conducted landmark analysis. Patients who survived for fewer than 3 months were excluded from the evaluation to reduce the immortal time bias. In total, 620 patients were evaluated, of whom 220 patients (35.5%) experienced grade ≥2 irAEs, including 134 patients with grade 2 irAEs and 86 with grade ≥3 irAEs. Propensity score matching extracted 198 patients with and without grade ≥2 irAEs. The onset of grade ≥2 irAEs was associated with longer median progression-free survival (PFS) (8.3 months vs. 4.5 months, p = 0.003) and overall survival (OS) (20.4 months vs. 14.3 months, p = 0.031) and a higher objective response rate (ORR) (44.8% vs. 30.2%, p = 0.004). Patients with grade 2 irAEs had significantly better oncological outcomes (PFS, OS, and ORR) than grade ≤1 and ≥3 irAEs. Patients with grade ≥3 irAEs had worse outcomes than grade 2 irAEs. Endocrine and skin irAEs were related with better survival outcomes, and the rate of severities was lower in these categories. In conclusion, the occurrence of irAEs, particularly low-grade irAEs, was predictive of pembrolizumab efficacy in patients with platinum-pretreated advanced UC.

Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for a dual-center, double-blind, randomized controlled trial.

BACKGROUND: An incision for total hip arthroplasty (THA) via the direct anterior approach (DAA) is generally made outside of the space between the sartorius and tensor fasciae latae muscles to prevent lateral femoral cutaneous nerve (LFCN) injury. Anatomical studies have revealed that the LFCN courses between the sartorius and tensor fasciae latae muscles. When the LFCN branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle, it is called the fan type. Studies suggest that damage to the fan type LFCN is unavoidable during conventional fasciotomy. We previously demonstrated that injury to non-fan variation LFCN occurred in 28.6% of patients who underwent THA by fasciotomy performed 2 cm away from the intermuscular space. This suggests that the conventional approach also poses a risk of LFCN injury to non-fan variation LFCN. LFCN injury is rarely reported in the anterolateral approach, which involves incision of fascia further away than the DAA. The purpose of this study is to investigate how the position of fasciotomy in DAA affects the risk of LFCN injury. METHODS: We will conduct a prospective, randomized, controlled study. All patients will be divided into a fan variation and a non-fan variation group using ultrasonography before surgery. Patients with non-fan variation LFCN will receive conventional fasciotomy and lateral fasciotomy in the order specified in the allocation table created in advance by our clinical trial center. The primary endpoint will be the presence of LFCN injury during an outpatient visit using a patient-based questionnaire. The secondary endpoints will be assessed based on patient-reported outcomes at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip-disease Evaluation Questionnaire, and the Forgotten-Joint Score-12. DISCUSSION: We hypothesize that the incidence of LFCN injury due to DAA-THA is reduced by making the incision further away from where it is typically made in conventional fasciotomy. If our hypothesis is confirmed, it will reduce the disadvantages of DAA and improve patient satisfaction. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000035945 . Registered on 20 February, 2019.

Impact of the objective response to and number of cycles of platinum-based first-line chemotherapy for metastatic urothelial carcinoma on overall survival of patients treated with pembrolizumab.

OBJECTIVES: To investigate the impact of the number of cycles and objective response to chemotherapy on overall survival in patients with metastatic urothelial carcinoma treated with pembrolizumab. METHODS: This multicenter, retrospective study included 755 patients from 59 institutions with advanced, chemoresistant urothelial carcinoma who received pembrolizumab. The associations of the overall survival with the number of cycles and best objective response were investigated using Cox multiple regression analysis. RESULTS: Overall, 391 patients received standard first-line chemotherapy and pembrolizumab as a second-line treatment, and were included in the final analysis. Of the 391 patients, 185 received less than four cycles, 134 received four to six cycles and 72 received more than six cycles of first-line chemotherapy. An objective response (complete or partial response) to chemotherapy was observed in 145 patients (37.1%). Univariate analysis showed that the overall survival of patients who received more than six cycles or responded to chemotherapy (complete or partial response) was significantly longer than that of patients who received less than four cycles or did not respond to chemotherapy (stable or progressive disease). At multivariate levels, no correlations were observed between overall survival and the number of cycles of or the response to chemotherapy. CONCLUSIONS: Therapeutic benefit of pembrolizumab can be expected irrespective of the objective response to and number of cycles of platinum-based first-line chemotherapy.

Does total hip arthroplasty via the direct anterior approach using dual mobility increase leg length discrepancy compared with single mobility?

BACKGROUND: Total hip arthroplasty (THA) via the direct anterior approach (DAA) using dual mobility cup (DMC) is considered to effectively prevent postoperative dislocation. However, the dislocation and reduction procedure using a trial implant during the surgery is difficult because of high soft tissue tension. Thereby, leg length discrepancy (LLD) is difficult to assess when using DM via the DAA. PURPOSE: To compare the LLD between cases using conventional SM and those using DMC in THA via the DAA with fluoroscopy. PATIENTS AND METHODS: We retrospectively investigated 34 hips treated with DMC (DMC-DAA group) and 31 hips treated with SM (SM-DAA group). The LLD was defined as the difference in the distance from the teardrop to the medial-most point of the lesser trochanter between the operative and nonoperative sides at immediate postoperative X-ray. RESULTS: The mean LLD in the DMC-DAA group and SM-DAA group was 0.68 ± 7.7 mm and 0.80 ± 5.5, respectively, with no significant difference. The absolute value of the LLD in the DMC-DAA group and SM-DAA group was 6.3 ± 4.4 mm and 5.9 ± 5.5, respectively, with no significant difference. CONCLUSION: Despite the difficulty in assessment of the LLD during THA via the DAA using DMC, this technique does not increase the LLD compared with the use of SM. LEVEL OF EVIDENCE: III, matched case-control study.

Inhibitory effect of omega-3 fatty acids on alveolar bone resorption and osteoclast differentiation.

In this study, a Porphyromonas gingivalis (P.g.)-infected mouse periodontitis model was used to investigate the effect of omega-3 fatty acid intake on differentiation and maturation of cultured osteoclast. Four-week-old C57BL/6JJcl mice were divided into four groups according to the diets they were fed from the beginning of the experiment (i.e., food containing omega-3 or omega-6 fatty acids) and whether they were orally administered P.g. Thirty-three days after beginning the experiment, bone marrow cells were sampled from the femoral bone of mice from each group and differentiated into osteoclasts; the effects of the ingestion of different fatty acids were subsequently investigated. There was no statistical interaction between the different fatty acids and P.g. infection on the number of osteoclasts (P = 0.6). However, the fatty acid type affected the number of osteoclasts in mice (P = 0.0013), with the omega-3 groups demonstrating lower osteoclast numbers than the omega-6 groups. Furthermore, the addition of resolvin E1 (RvE1), which is an omega-3 fatty acid-derived lipid mediator, suppressed the differentiation of mouse cultured osteoclasts (P < 0.0001). Therefore, the ingestion of omega-3 fatty acids may suppress osteoclast differentiation while inhibiting bone resorption and tissue destruction due to periodontitis.

Autograft-prosthesis composite use for a Vancouver type B1 periprosthetic femur fracture with pelvic acetabular component migration after bipolar hemiarthroplasty: A case report.

INTRODUCTION: Bipolar hemiarthroplasty (BHA) is a commonly performed procedure for elderly patients with an intra-capsular fracture of the femoral neck. However, surgeons performing BHA worry about the rate of acetabular wear, and acetabular prosthesis protrusion can pose a challenging surgical problem. The number of periprosthetic femur fractures is expected to increase. Generally, well-fixed stems require open reduction and internal fixation (ORIF), whereas loose stems require revision arthroplasty. CASE REPORT: A 68-year-old Asian woman was admitted to our hospital. She had sustained a left displaced femoral neck fracture at the age of 58 years. BHA was performed via a posterior approach in another hospital. Ten years later, she presented with severe left hip pain following a low-energy fall. A radiograph of the hip joint demonstrated a Vancouver type B1 periprosthetic femur fracture with severe acetabular prosthetic protrusion. Single-stage reconstructive surgery was performed. A transgluteal approach was used, with distal extension to the fracture site of the femur. Acetabular reconstruction was performed using a Kerboull-type plate in combination with massive allografts for the large bone defects of the acetabulum. Regarding the femoral side, the proximal bone fragment and cementless stem that had been fixed were longitudinally opened with an osteotomy and separated. After that, the stem was changed to a cemented long stem and combined with the prior proximal bone fragments using cement and wires in an allograft-prosthesis composite technique (autograft-prosthesis composite). CONCLUSION: Although the standard treatment for Vancouver type B1 periprosthetic femur fractures is ORIF, it would have been difficult to reconstruct the hip joint solely with osteosynthesis because the femur was severely shortened by marked migration of the BHA. Single-stage reconstructive surgery using an autograft-prosthesis composite was effective treatment for a Vancouver type B1 periprosthetic femur fracture with concomitant severe acetabular prosthetic protrusion after BHA.

Posterior versus direct anterior approach in total hip arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score-12.

INTRODUCTION: When the postoperative outcome of primary total hip arthroplasty (THA) was compared with the direct anterior approach (DAA) and the posterior approach (PA), there was no significant difference of the clinical outcome at 6 months to 1 year after surgery in many studies. This study was performed to compare the medium-term outcome of THA via the DAA or PA and clarify which approach achieves better quality of life (QOL). METHODS: We investigated 61 hips receiving primary THA (30 via DAA and 31 via PA), using hip function scores such as the Harris Hip Score (HHS) and patient-reported outcomes such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS). RESULTS: The mean duration of postoperative follow-up was 36.8 months in the DAA group and 40.5 months in the PA group. There was no difference in preoperative or postoperative HHS between the two groups. Although there was no difference of postoperative WOMAC and JHEQ, the postoperative FJS-12 score was significantly higher in the DAA group than in the PA group (75.2 ± 15.9 versus 60.1 ± 24.4, p = 0.01). CONCLUSION: When forgetting the artificial joint in daily life is the target, better QOL can be achieved by performing THA via the DAA.

Preoperative ultrasound to identify distribution of the lateral femoral cutaneous nerve in total hip arthroplasty using the direct anterior approach.

INTRODUCTION: Recently, the branching pattern of the lateral femoral cutaneous nerve (LFCN) named Fan type has been reported that LFCN injury cannot be avoided in surgical dissections that use the direct anterior approach to the hip joint in the cadaveric study. We hypothesized that the Fan type can be identified by ultrasound The aim of this study was to investigate whether LFCN injury occurs in DAA-THA in cases identified as the Fan type based on preoperative ultrasound of the proximal femur. METHODS: Ultrasonography of the proximal femur on the surgical side was performed before surgery and the LFCN distribution was judged as the Fan type or Non-Fan type. A self-reported questionnaire was sent to the patients at two months after surgery, and the presence or absence of LFCN injury was prospectively surveyed. RESULTS: After application of exclusion criteria, 45 hips were included. LFCN injury was observed after surgery in 9 of the 10 patients judged as the Fan type based on the ultrasound of the proximal femur (positive predictive value: 90%), and no LFCN disorder was actually observed in 25 of the 26 patients judged as Non-Fan type (specificity: 96.2%). CONCLUSIONS: To prevent injury of the LFCN in patients judged as the Fan type on the ultrasound test before surgery, the risk of direct injury of the LFCN may be reduced through the approach in which an incision is made in the fascia which is opposite to the radial spreading, i.e., between the sartorius and tensor fasciae latae muscles or slightly medial from it.

The Baba classification focused on implant designs is useful in setting the therapeutic strategy for interprosthetic femoral fracture.

PURPOSE: The purpose of this study was to investigate the clinical outcomes of femoral fracture with implants on the proximal and distal sides to verify whether actual fracture morphologies follow the fracture types of Baba classification focusing on implant designs useful for periprosthetic femoral fracture. METHODS: Prosthesis was present in 85 with periprosthetic femoral fractures. Excluding 73 patients with fracture around the femoral stem or fracture of the TKA femoral component alone, 12 patients with 14 legs with both implants were investigated. All patients were radiographically assessed for implant stability according to the Baba classification. For clinical evaluation, intra- and postoperative complications, the operation time, and intra-operative blood loss were investigated. RESULTS: The Baba classification fracture type showed the implant as unstable and stable types in 3 and 11 legs, respectively. The consistency rate between the Baba classification-based judgment of plain radiograms acquired at the time of injury and actual surgical findings was 100%. As a result of treatment according to the Baba classification, bone union was achieved in all patients. There were no intra- or postoperative complications. CONCLUSIONS: Applying the Baba classification, implant stability could be sufficiently evaluated in not only periprosthetic femoral fractures following hip arthroplasty, but also interprosthetic femoral fractures, thereby verifying its usefulness in setting the treatment strategy.

Total hip arthroplasty via the direct anterior approach with a dual mobility cup for displaced femoral neck fracture in patients with a high risk of dislocation.

INTRODUCTION: Although total hip arthroplasty (THA) is superior to bipolar hemiarthroplasty (BHA) for displaced femoral neck fracture in terms of hip pain, function and reoperation rate, THA has a higher rate of dislocation. The direct anterior approach (DAA) and a dual mobility cup (DMC) are associated with lower rates of dislocation. The aim of this study was to investigate the outcomes of THA compared with BHA, and in those patients who had a THA we investigated those with a DMC (DMC-THA) and compared them with those had a single conventional cup (Single cup-THA). MATERIALS: A total of 89 patients living independently were included between 2009 and 2015. We assessed patient characteristics, peri- and post-operative outcomes, walking ability and one-year mortality. Adjusted odds ratios (Adjusted ORs) were estimated for decrease of walking ability and one-year mortality using a logistic regression model with adjustment for potential confounders such as age, neuromuscular diseases with weakness, duration of surgery, perioperative blood loss and preoperative walking ability. RESULTS: BHA (20 patients) versus THA (69 patients): There was no significant difference in the walking ability in either group. Multivariable logistic regression analysis demonstrated a significant association with one-year mortality in both groups [THA Adjusted ORs 0.088 (95% CI 0.0007-0.69); p = 0.020]. Single cup-THA (36 patients) versus DMC-THA (33 patients): The DMC-THA group had significantly greater age and more patients with neuromuscular diseases with weakness compared with the Single cup-THA group. Multivariable logistic regression analysis demonstrated no significant difference in the decrease of walking ability and in the one-year mortality between the groups. There were no post operative dislocations in any group. DISCUSSION: THA via the DAA is one of the best treatments for displaced femoral neck fracture with a low risk of dislocation. THA via the DAA with a DMC is a safe and effective treatment for the patients with a high risk of dislocation.

Safe and Effective Reduction Technique for Intertrochanteric Fracture with Ipsilateral Below-Knee Amputated Limb.

The positioning of the patient on the fracture table is critical for the successful reduction and operative fixation of intertrochanteric hip fractures. However, this manipulation is challenging with patients who have undergone amputations of their legs. A 97-year-old man presented to the emergency department with symptom of right hip pain following a mechanical fall. He had a below-knee amputation on his right leg following a traffic accident as a 19-year-old and had a below-knee patellar tendon bearing prosthesis fitted to his lower limb for mobility. Radiographs of his pelvis revealed a displaced intertrochanteric fracture of the right side femur. The patient was positioned on a fracture table, as in the standard procedure. The method of inverting the traction boot to accommodate the flexed knee and stump described by Al-Harthy could be used to provide traction and rotational control. Internal fixation was performed using a short femoral nail. Postoperatively, the patient could walk with full weight bearing using a prosthesis on his affected limb. The method of inverting the traction boot to accommodate the flexed knee and stump can be used safely and effectively to achieve and maintain fracture reduction during fixation of intertrochanteric fractures for patients with a below-knee amputated limb.

Long-term results of rotational acetabular osteotomy for osteonecrosis with collapse of the femoral head in young patients.

PURPOSE: The surgical treatment of osteonecrosis with collapse of the femoral head is still controversial. The purpose of this study was to investigate the clinical outcome of rotational acetabular osteotomy by Ninomiya and Tagawa for osteonecrosis of the femoral head in young patients. PATIENTS AND METHODS: Rotational acetabular osteotomy was performed in 202 consecutive patients between 1995 and 2003. Among them, rotational acetabular osteotomy with osteonecrosis of the femoral head was performed in 31 patients (42 hips). The mean age at the time of surgery was 31.2 years (range 16-45). The mean duration of follow-up was 16.1 years (range 13.1-21 years). RESULTS: The mean preoperative Japanese Orthopedic Association hip score of 56.8 points improved to a mean of 72.4 points at the final follow-up. The 10-year survival rate with conversion to total hip arthroplasty as an end-point was 91.9%, and the 15-year survival rate was 75.5%, the 20-year survival rate was 67.9%. The conversion to total hip arthroplasty was performed in nine hips. The average time to the conversion to total hip arthroplasty was 12.1 years. CONCLUSIONS: Even though the necrotized range is wide, if normal cartilage remains on the lateral side of the femoral head, it can be utilized for the weight-bearing region by laterally rotating the acetabulum. Since the outcome was favorable, we believe that this is a valuable treatment option for this disease.

Influence of the contralateral hip state after total hip arthroplasty on patient-reported outcomes measured with the Forgotten Joint Score-12.

PURPOSE: The purpose of this study was to examine the influence of the contralateral hip state on postoperative assessment using the Forgotten Joint Score-12 (FJS-12) in comparison with the McMaster Universities Osteoarthritis Index (WOMAC) and the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). METHODS: One hundred and thirty-four hips underwent total hip arthroplasty (THA) between 2014 and 2015. Of these, the subjects were 106 hips with degenerative hip arthrosis as a primary disease for whom initial THA was performed on the affected side. The WOMAC and JHEQ were investigated before surgery and 1 month, 6 months, and 1 year after surgery. The FJS-12 was examined 1 month, 6 months, and 1 year after surgery. RESULTS: We divided the subjects into three groups based on the state of the contralateral hip, which was not surgically treated in this study: healthy (n = 43), THA (n = 31), and OA (n = 31) groups. One year after surgery, the mean FJS-12 scores in the healthy, THA, and OA groups were 69.1, 52.8, and 68.0 points, respectively. In the THA group, the score was significantly lower than in the healthy and OA group. There were no significant differences in WOMAC and JHEQ scores among the three groups. CONCLUSIONS: The FJS-12 score in the presence of an arthroplasty on the contralateral side was more markedly influenced by the contralateral hip state compared with that in the presence of contralateral painful OA. This result suggests that it is necessary to understand the characteristics of PROs and utilize them for post-THA assessment.

Kerboull-type plate in a direct anterior approach for severe bone defects at primary total hip arthroplasty: technical note.

INTRODUCTION: For cases with extensive acetabular bone defects, we perform surgery combining the Kerboull-type (KT) plate and bone graft through direct anterior approach (DAA) in primary total hip arthroplasty (THA) requiring acetabular reconstruction as minimally invasive surgery. This paper provides the details of the surgical procedure. METHODS: The basic structure of the Kerboull-type plate is a cruciform plate. Since the hook of the Kerboull-type plate has to be applied to the tear drop, a space for it was exposed. The tear drop is located in the anterior lower region in surgery through DAA in supine position. It was also confirmed by fluoroscopy as needed. The bone grafting was performed using an auto- or allogeneic femoral head for bone defects in the weight-bearing region of the hip joint. RESULTS: Of 563 patients who underwent primary THA between 2012 and 2014, THA using the KT plate through DAA was performed in 21 patients (3.7%). The mean duration of postoperative follow-up was 31.8 months. The mean operative time was 188.4 min, and the mean blood loss was 770 g. The patients became able to walk independently after 2.4 days on average (1-4 days). On clinical evaluation, the modified Harris Hip Score was 45.6 ± 12.4 before surgery, and it was significantly improved to 85.3 ± 8.97 on the final follow-up. DISCUSSION: DAA is a true intermuscular approach capable of conserving soft tissue. Since it is applied in a supine position, fluoroscopy can be readily used, and it was very useful to accurately place the plate.

Spontaneous healing of lateral femoral cutaneous nerve injury and improved quality of life after total hip arthroplasty via a direct anterior approach.

PURPOSE: How the symptomatology of lateral femoral cutaneous nerve (LFCN) injury changes after total hip arthroplasty (THA) via direct anterior approach (DAA) is not known. Our hypothesis was that the symptoms of LFCN injury after THA via DAA in longer follow-up periods would resolve spontaneously, leading to an improved quality of life (QOL). The aims of this study were to investigate how the symptom LFCN injury changed after DAA-THA, and how those changes affected QOL. METHODS: We investigated the incidence of LFCN injury after DAA-THA using self-reported questionnaires at two time points (initial survey: August 2014, present survey: August 2015). QOL was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, and the Forgotten Joint Score-12 (FJS-12). Types (dysesthesia or hypesthesia) and changes of the symptom were surveyed. RESULTS: About 122 hips at average12.8 months postoperatively (initial survey), and of those, 89 hips at average 26.2 months postoperatively (present survey) were analyzed. The incidence of LFCN injury decreased significantly, from 31.9% to 11.2% ( p < 0.001). Spontaneous improvement of symptoms was seen in 96%. The difference of FJS-12 between patients with and without LFCN injury at the initial survey disappeared at the present survey. The dysesthesia group showed significant correlations between rate of improvement in LFCN injury and increase of QOL. CONCLUSION: Most symptoms of LFCN injury resolved spontaneously with longer follow-up periods. In particular, improvement of dysesthesia as a symptom of LFCN injury was associated with better QOL.

In total hip arthroplasty via the direct anterior approach, a dual-mobility cup prevents dislocation as effectively in hip fracture as in osteoarthritis.

PURPOSE: The main purpose of this study was to compare the outcome of total hip arthroplasty (THA) via the direct anterior approach (DAA) using a dual-mobility cup (DMC) in patients with femoral neck fracture to those in patients undergoing elective THA for osteoarthritis. PATIENTS AND METHODS: We retrospectively investigated 40 hips with femoral neck fracture (group A), and 81 hips with osteoarthritis (group B). THA via the DAA using the DMC was performed in both groups. A primary/secondary outcome variable were the presence of dislocation/operative time, intra- and/or peri-operative complication, and mortality. RESULTS: Dislocation did not occur in either group. The complication rate was slightly higher in group A than in group B, but not statistically significant. CONCLUSION: THA with the DMC using the DAA was as effective for femoral neck facture as it was for elective THA in patients with osteoarthritis.