Femoroacetabular impingement: question-driven review of hip joint pathophysiology from asymptomatic skeletal deformity to end-stage osteoarthritis.

Femoroacetabular impingement (FAI), together with its two main pathomechanisms, cam and pincer, has become a trending topic since the end of the 1990s. Despite massive academic research, this hip disorder still conceals obscure aspects and unanswered questions that only a question-driven approach may settle. The pathway that leads a FAI asymptomatic morphology through a FAI syndrome to a FAI-related osteoarthritis is little known. Contact mechanics provides a shareable and persuasive perspective: cam FAI is based on shear contact stress at joint level with consequent cartilage wear; pincer FAI, contrariwise, determines normal contact stress between acetabular rim and femoral neck and squeezes the labrum in between, with no cartilage wear for many years from the onset. Pincer prognosis is then far better than cam. As a matter of fact, cartilage wear releases fragments of extracellular matrix which in turn trigger joint inflammation, with consequently worsening lubrication and further enhanced wear. Inflammation pathobiology feeds pathotribology through a vicious loop, finally leading to hip osteoarthritis. The association of cam and pincer, possibly overdiagnosed, is a synergic combination that may damage the joint rapidly and severely. The expectations after FAI surgical correction depend strictly on chondral layer imaging, on time elapsed from the onset of symptoms and on clinic-functional preoperative level. However, preemptive surgical correction is not recommended yet in asymptomatic FAI morphology. LEVEL OF EVIDENCE: V.

Subradiological cam deformity of the head-neck junction: an occult cause of hip pain and chondrolabral damage.

PURPOSE: The goal of this study was to determine how frequently the conventionally defined "idiopathic" chondrolabral hip injuries are associated with subradiological cam deformities of the head-neck junction and whether a protective femoral osteochondroplasty may improve the outcome of their arthroscopic treatment. METHODS: All the non-arthritic or pre-arthritic painful hips diagnosed as having a primary chondrolabral injury were retrospectively evaluated. Coxometric data, clinical history and physical findings were reviewed to rule out any possible secondary lesion. The medical records of the selected cases were analyzed as for imaging features, surgical findings and post-arthroscopy outcome. RESULTS: Three cases out of 79 chondrolabral injuries were identified as "primary" on the basis of the preoperative assessment. All the three patients were female in their fourth decade and showed a joint damage consistent with undetected cam FAI (cartilage delamination in the anterolateral acetabular quadrant, minor pathology of the adjacent labrum with or without chondrolabral separation, abrasion signs and herniation pits along the anterolateral head-neck junction). The first patient received a simple chondrolabral treatment whose benefits deteriorated few months after surgery; the second patient underwent chondrolabral repair and femoral osteochondroplasty and is still pain-free; and the third patient had a beneficial revision arthroscopy for femoral osteochondroplasty after prior unsuccessful chondrolabral surgery. CONCLUSIONS: If a chondrolabral injury of the hip is associated with MR arthrographic and arthroscopic indirect signs of cam FAI, a subradiological head-neck deformity should be considered despite normal alpha angles. In such cases, a protective femoral osteochondroplasty may increase the success rate of the chondrolabral repair. LEVEL OF EVIDENCE: IV.

Trabecular metal cup without augments for acetabular revision in case of extensive bone loss and low bone-prosthesis contact.

Current evidences in revision hip arthroplasty suggest to treat severe acetabular bone loss with dedicated implants, such as anti-protrusio cages, stemmed cups, modular systems supplied with iliac flanges and obturatory hook. However recent literature is reporting satisfactory outcomes with simple elliptical Trabecular Metal cups. Purpose of the study was to evaluate mid-term results of such a surgical procedure. All hip revisions performed from 2008 to 2009 with implantation of a TMT multi-hole acetabular cup without augmentations were retrospectively reviewed. The cases with low-degree acetabular bone loss (stage I and II according to GIR classification), with surgical report poorly describing the bone defect, with inadequate pre- and post-operative x-rays were ruled out. Twenty-five cases were identified, but four were lost to follow-up. The twenty-one patients were 71 year-old on average (from 60 to 82), with stage IV bone loss in 6 cases and stage III bone loss in 15 cases. Mean interval from surgery to evaluation was 20.9 months (from 13 to 30). The evaluation included bone-prosthesis contact estimation, component position, survivorship, complications, final Harris Hip Score, presence of periprosthetic radiolucencies. Host bone-prosthesis contact was estimated to be about 35%. Only three implant were subsequently reoperated (for infection, early migration, recurrent dislocation). The HHS among non-reoperated 18 patients was 81.96 on average (from 63.44 to 95.82). Six cases showed thin radiolucencies in one of the three Charnley zones, while three cases showed radiolucencies in two. None of these images was evolutive, thus they were not considered signs of loosening. The mid-term results of this series confirm the hypothesis that a porous tantalum acetabular cup is an effective option to deal with difficult acetabular revisions. Although no extra-acetabular fixation device is available, the very high surface friction guaranteed by the material and the supplemental stability provided by trans-acetabular screws seem to be sufficient to allow satisfactory reimplantation even in severely damaged pelves.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

How to write an original article for the Journal of Orthopaedics and Traumatology.

The abstract is the precise summary of the article, not a preface. As Baue wrote in a popular editorial of the Archives of Surgery in 1979, "writing a good abstract is not abstract writing" [6]. The main data have to be represented, as they allow readers to understand contents clearly. Sentences like "The paper reports..." or "The authors describe..." have to be avoided as well as any generic statements.In order to help writers avoid generalities, the recently revised version of this journal's "instructions to authors" [4] requires the abstract to be no longer than 300 words and structured in 4 paragraphs: the Background declares the hypothesis, the Materials and methods impart the study design and quote the relevant numerical features of the samples, the Results report the main data and their statistical significance, the Conclusions state whether the hypothesis is verified or not. One or two sentences per paragraph are usually sufficient.The abstract is frequently recommended to be written after the text, as "the process of writing changes thought and perhaps even purpose" [7]. Nonetheless, in my view, preparing the abstract first is a useful exercise that forces the authors to organize their thoughts and guides the organization of the article. However, the abstract should be always revised after the manuscript has been completed.