Do joint-preserving hip procedures compromise subsequent total hip arthroplasty? A meta-analysis of complications, functional outcome and survivorship.

BACKGROUND: Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. METHODS: MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. RESULTS: 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6-11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6-200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2-3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0-3.2], implant loosening [RR: 1.0, 95% CI: 0.7-1.5], or revision surgery [RR: 1.3, 95% CI: 1.0-1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: -5.6, 95% CI: -7.6-(-3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6-6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4-4.7], specifically, with prior femoral osteotomy. CONCLUSION: Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.

Bilateral tibial fractures associated with powered exoskeleton use in complete spinal cord injury - a case report & literature review.

INTRODUCTION: Powered robotic exoskeleton (PRE) physiotherapy programmes are a relatively novel frontier which allow patients with reduced mobility to engage in supported walking. Research is ongoing regarding their utility, risks, and benefits. This article describes the case of two fractures occurring in one patient using a PRE. CASE: We report the case of a 54 year old man who sustained bilateral tibial fractures while using a PRE, on a background of T10 AIS A SCI. The initial session was discontinued due to acute severe bilateral knee swelling after approximately 15 min. The patient attended their local hospital the following day, where radiographs demonstrated bilateral proximal tibial fractures. The patient was treated with manipulation under anaesthetic and long-leg casting for five weeks, at which point he was stepped down to hinged knee braces which were weaned gradually while he remained non-weight bearing for 12 weeks. The patient was investigated with DEXA scan and was diagnosed with osteoporosis. He was liaised with rheumatology services and bone protection was initiated. Fracture healing was achieved and weight-bearing precautions were discontinued, however this period of immobilisation led to significant spasticity. The patient was discharged from orthopaedic services, with ongoing rehabilitation and physiotherapy follow-up. CONCLUSION: PRE assisted physiotherapy programmes are a promising concept in terms of rehabilitation and independence, however they are not without risk and it is important that both providers and patients are aware of this. Furthermore, SCI patients are at increased risk for osteoporosis and should be monitored and considered for bone protection.

Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

Battle of the titans: Survivorship analysis of the 3 most common types of uncemented femoral stems used across national registries.

Background: Although many institutions utilize uncemented stems as routine in performing total hip arthroplasty (THA), many surgeons continue to rely on outcomes reported in the literature in the form of small cohorts and patient series when analyzing survivorship for specific implants. The purpose of this study was to identify and analyze the survivorship of the 3 most common uncemented stem types (as opposed to brands) used across multiple national joint registries. Methods: A review of data available from all national joint registries was carried out in July 2022. Analysis of each individual registry and classified uncemented implants into the seven different uncemented stem types. The 3 most common stem types were identified, and average cumulative revision rates calculated. Metal on metal bearings surface implants were excluded from this study due to high revision rates across all implant types. Results: Our detailed review identified 6 out of 13 (NJR, AOANJRR, LROI, EPRD, MARCQI and the NZJR) international registries reporting implant specific survivorship on uncemented femoral stems; including 960,328 uncemented stems across all registries. The most common type of stem used was type 3c, accounting for 61% (583,724), followed by type 1 stems with 23% (217,897) and type 2 stems with 8% (79,257). Cumulative revision rates at 13 years follow-up for these stems ranged from 6.9% to 7.9%. Conclusion: Although all stem types have comparable revision rates across all registries, the most common uncemented stem reported was the type 3c, tapered rectangular fully coated stem. Furthermore, out of all type 3c, the Müller design philosophy with full hydroxyapatite coating seems to be the most sought after worldwide. In this study we can conclude, thus far, that there does not appear to clinical or statistical differences in revision rates between the different stem types. Level of evidence: III.

Increasing hip fracture volume following repeated lockdowns: an Irish multicentre study of periods pre-Covid, during Covid lockdown and following vaccination.

BACKGROUND: Older age groups were identified as a high-risk cohort for Covid-19 and thus were a focus of lockdown measures enacted internationally. Resultant decreased social mobility and physical activity levels are associated with sarcopenia, which may lead to increased risk of hip fracture upon resuming social integration and physical activities after easing of lockdown restrictions. AIMS: Our aim was to compare the incidence of hip fractures during the period following vaccination with subsequent relaxation of restrictions, to those prior to and during the Covid pandemic. METHODS: A multicentre retrospective cohort study was performed consisting of all patients presenting with a "hip" fracture to 3 regional trauma units over the relevant time periods in 2019, 2020 and 2021. Tallaght, Galway and Waterford University Hospitals are large academic teaching hospitals with a combined mixed urban and rural catchment of over 1 million people. FINDINGS: Four-hundred-fourteen patients in total were included in the final analysis, with 133 eligible hip fractures observed proceeding to operative treatment across the study period in 2019, 132 in 2020 and 149 in 2021, representing a 12.88% increase. Demographic data revealed similar patient cohorts with respect to age and gender, fracture pattern and treatment. CONCLUSIONS: An increase in hip fracture volume was observed during the period post vaccination with subsequent relaxation of restrictions and increased social mobility, compared to those prior to and during the Covid pandemic. These findings have implications for hospital planning and orthopaedic resourcing as we navigate our way forward past the Covid-19 Pandemic.

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative.

Background Clear, accurate written documentation plays an important role in the handover of medical information, helping to improve care efficiency and avoid medical errors. Both HSE and the Irish National Orthopaedic Models of Care guidelines include key documentation standards for admission notes. Standardised medical admission proforma can help improve documentation standards, but their usage across Irish orthopaedic units is limited to three centres. We evaluated whether an admission proforma improved the documentation standards of acute orthopaedic trauma admission notes within our regional trauma unit. Methods Cycle 1 consisted of a retrospective review of 50 consecutive acute orthopaedic trauma admissions. Exclusion criteria included planned admissions, age <16 years, spinal or pelvic trauma, and 'hip' fractures for whom an existing proforma was in use. Cycle 2 consisted of a prospective review of 50 consecutive acute trauma admissions using the new proforma. Each cycle was scored against a pre-determined checklist incorporating Irish Health Service Executive and Orthopaedic Models of Care documentation standards, with results collated and statistical analysis then performed using Fisher's exact test. Findings Significant improvements in admission note compliance with national documentation were observed. This encompassed multiple domains including clinical identification, e.g., consultant identification (78% to 100% p=0.0005), clinical history, time of injury (72% to 100% p=0.0001), medical history, smoking status (86% to 100% p=0.0001), and patient assessment, vital signs (28% to 70% p=0.0001). Conclusion Improvements in admission note compliance with national documentation standards followed the introduction of a standardised proforma. These findings may encourage the introduction of similar proforma in other units, with potential benefits in patient care.

Retching as an unusual cause of bilateral posterior shoulder fracture dislocation.

Bilateral posterior shoulder fracture dislocation is a debilitating injury and is quite rare. This injury pattern has been described in the literature as either secondary to seizure, electrocution or major trauma. We present a case of an elderly man who appears to have sustained the injury after an episode of retching and vomiting. With our patient witnessed closely throughout and no trauma, electrocution or seizure activity reported, we propose that the violent action of retching and vomiting not only has the potential to cause this injury pattern but also was the only credible cause in our patient. This case not only adds to the list of potential injuries caused by retching and vomiting but also questions the validity of a previously limited list of modes-of-injury for posterior shoulder fracture dislocation.

Low-Intensity Pulsed Ultrasound Therapy in Patients With Post-traumatic Delayed Union and Non-union.

Background Fracture non-union can lead to significant patient morbidity with poor quality of life. Due to the cost, complexity, and potential risks of revision surgery, there has been an increased popularity in the use of low-intensity pulsed ultrasound therapy (LIPUS), which accelerates and promotes bone consolidation. There is an ongoing debate regarding the use and efficacy of LIPUS in delayed union and non-union. This study aims to assess the success rate of LIPUS therapy in patients treated for delayed and non-union fractures, explicitly focusing on the impact of patient co-morbidities and fracture characteristics. Method A retrospective observational study was performed of all consecutive patients who received LIPUS therapy in a single institution from January 2016 to September 2022. Of 127 identified patients, only 99 patients met our inclusion criteria. Data collection entailed reviewing the clinical notes to assess patients' sex, age, co-morbidities, initial treatment method, time to initiate LIPUS, whether a CT was performed to diagnose non-union, time to union and whether revision surgery was needed. Two independent senior orthopedic doctors reviewed the patients' radiographs, measured the interfragmentary bone gap of all fractures, and assessed whether the radiographic union was achieved. Results The mean age of the included patients was 52.5 (SD±16.9) years with a male-to-female ratio of 1:1.6. At initial presentation, 65 (out of 99) patients were treated surgically, whereas the rest were managed conservatively. 80.8% of patients developed atrophic non-union. All 99 included patients were fitted with LIPUS once delayed/ non-union was diagnosed; the average time to fitting was 5.1 (SD±3.9) months. Of these, 61.6% of patients were successfully treated with LIPUS with a clinical and radiological union at an average of 4.3 (SD±1.9) months. The rest of the patients needed further surgical intervention due to ongoing non-union. The interfragmentary bone gap was the only statistically significant factor influencing the success of LIPUS therapy (p=0.003). In contrast, no statistically significant association was identified between the outcome of LIPUS therapy and the patient's age, sex, diabetes, and smoking status. Conclusion This study demonstrated a 61.6% progression to union rate of patients treated with LIPUS therapy for delayed union and non-union. The interfragmentary bone gap was identified as the only statistically significant factor influencing the success of LIPUS therapy. In the current climate post-lockdown and with ongoing Covid 19 outbreaks impacting elective waiting lists negatively, there is increased value and demand for non-surgical treatment options. LIPUS therapy represents an important complementary non-surgical and low-risk treatment pathway for delayed union and non-union.

Informed Written Consent for Orthopaedic Trauma in the Emergency Setting at a Tertiary Referral Centre: A Closed-Loop Audit.

Introduction The purpose of this investigation was to perform an audit of the standards of consent forms in which patients sign prior to operative intervention for orthopaedic trauma in an emergency setting in our institution, with comparison to the 'Orthopaedic Surgical Consent' standards, as set by the American Association of Orthopaedic Surgeons (AAOS). If required, the investigator aimed to close the loop in this audit by educating orthopaedic surgeons on the necessary standards of obtaining written consent for orthopaedic trauma. Methods Following being granted approval by our institutional audit committee, a pre-intervention cycle was performed to assess the quality of consent obtained in written format using electronic patient records in consecutive patients over a four-week period. Following the analysis of this data, an education session was provided for all orthopaedic doctors responsible for obtaining informed written consent from patients who are planned to undergo operative management of a soft tissue or bony injury by the trauma and orthopaedic service in the emergency setting. Thereafter, a post-intervention cycle was performed with subsequent descriptive analysis using the GraphPad software. Results In the pre-intervention audit cycle, all included (n = 107) consent forms (100%) correctly included the patient's name, date of birth (DOB) and institutional board number (BN). However, only 79 consent forms (74.5%) were completed without using abbreviations or acronyms of any kind, whilst 81 consent forms (76.4%) were completed without correctly stating the side or site of the planned intervention. In the post-intervention cycle, all included (n = 40) consent forms (100%) correctly included the patient's name, DOB and institutional BN. Additionally, a total of 37 consent forms (92.5%) were correctly completed without using abbreviations or acronyms of any kind (74.5% versus 92.5%, p = 0.02). Furthermore, a total of 39 consent forms (97.5%) were completed correctly stating the side or site of the planned intervention (76.4% versus 97.5%, p = 0.0015). Conclusion This closed-loop audit found that the quality of informed consent obtained by orthopaedic surgeons in the emergency setting might potentially be significantly improved with at least one virtual education session. Such simple education sessions may potentially improve the documentation of the planned potential operative intervention by orthopaedic surgeons for cases of orthopaedic trauma to ensure patient safety is optimised. As the turnover of non-consultant hospital doctors is high in university teaching hospitals, regular education sessions on such topics may introduce a cultural shift in maintaining high standards when marking and consenting patients in the emergency setting.

Does Proximal Femoral Morphology Impact Morbidity and Mortality? A Cohort Study of Uncemented Hemiarthroplasties in the Treatment of Femoral Neck Fractures.

BACKGROUND: To assess outcomes after uncemented hemiarthroplasty stems in the treatment of intracapsular femoral neck fractures over an 11-year period. Mortality rates were assessed, and whether proximal femoral geometry and stem alignment were factors in intraoperative or postoperative periprosthetic fracture (PPF) needs to be identified. MATERIALS AND METHODS: A retrospective single-center observational study was conducted of all patients who underwent intracapsular femoral neck fracture treatment using an uncemented prosthesis between January 2008 and December 2018. Primary endpoints included mortality rate, Dorr classification, prosthesis alignment, intraoperative fracture, and reoperation rate for any reason. Subanalysis on collared and uncollared implants was also conducted. Multivariate logistic regression was performed based on Dorr classification for stem alignment, fracture incidence, reoperation rate, implant sizing, and patient mortality. RESULTS: A total of 536 patients received an uncemented hemiarthroplasty in the study period. The mean patients age was 80.4 years, of which 71% were female. The 30-day mortality rate was 5.2%, with no deaths on day zero or day one. Twenty patients (3.7%) sustained an intraoperative calcar fracture, and 14 patients a PPF (2.6%) at a mean of 1.3 years from surgery. Dorr C type femurs were more likely to develop a PPF (P = .001), while valgus stem alignment was associated with PPF (P = .049). CONCLUSIONS: This implant has low reoperation rates, low early postoperative mortality, and low 30-day mortality. This large single-center study provides up-to-date information using a contemporary stem in patients with multiple comorbidities. Dorr C femoral morphology and valgus stem malalignment were risk factors for postoperative fractures.

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures.

BACKGROUND: Uncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA. METHODS: A retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment. RESULTS: Over the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004). CONCLUSION: UHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.

Perioperative Mortality After Cemented or Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures-A Systematic Review and Meta-analysis.

BACKGROUND: Debate surrounds the use of cemented or uncemented prostheses for the treatment of displaced femoral neck fractures (FNF). Many guidelines recommend the use of the cemented hemiarthroplasty (CHA). Proponents of CHA point out the increased re-operation rate while proponents of uncemented hemiarthroplasty (HA) highlight the increased mortality rate in the perioperative period. The aim of this study was to systematically review the literature to evaluate perioperative mortality after HA for displaced FNFs. METHODS: A systematic review and meta-analysis was performed of MEDLINE, Cochrane Library, and Embase databases evaluating perioperative mortality after HA for displaced FNFs. Randomized control trials and observational studies were included comparing current-generation stem designs. A meta-analysis was performed on studies that directly compared the different modes of fixation. RESULTS: Twenty-two studies were included (seven randomized control trials and 15 observational studies), with a total of 183,167 HAs for treatment of a displaced FNF. Fourteen studies were included in the meta-analysis. There was a higher cumulative odds of death within the first 48 hours in those with CHA compared with uncemented HA (OR: 1.64; 95% CI: 1.35, 2.00; P ≤ .01). No difference was found in mortality at 7 days, 30 days, and one year. CONCLUSION: CHA is associated with an increased mortality rate within the first two days of surgery with no difference at 7 days, 30 days, and one year. Surgeons should consider tailoring their stem choice based on the physiological status of the patient when planning HA for FNFs. Techniques to reduce the risk of bone cement implantation syndrome should be used.

Current concepts and outcomes in cemented femoral stem design and cementation techniques: the argument for a new classification system.

Cemented implant fixation design principles have evolved since the 1950s, and various femoral stem designs are currently in use to provide a stable construct between the implant-cement and cement-bone interfaces.Cemented stems have classically been classified into two broad categories: taper slip or force closed, and composite beams or shaped closed designs. While these simplifications are acceptable general categories, there are other important surgical details that need to be taken into consideration such as different broaching techniques, cementing techniques and mantle thickness.With the evolution of cemented implants, the introduction of newer implants which have hybrid properties, and the use of different broaching techniques, the classification of a very heterogenous group of implants into simple binary categories becomes increasingly difficult. A more comprehensive classification system would aid in comparison of results and better understanding of the implants' biomechanics.We review these differing stem designs, their respective cementing techniques and geometries. We then propose a simple four-part classification system and summarize the long-term outcomes and international registry data for each respective type of cemented prosthesis. Cite this article: EFORT Open Rev 2020;5:241-252. DOI: 10.1302/2058-5241.5.190034.

Impact of Type 2 Diabetes Mellitus on Human Bone Marrow Stromal Cell Number and Phenotypic Characteristics.

Human bone marrow-derived mesenchymal stromal cells (MSCs) have been investigated in numerous disease settings involving impaired regeneration because of the crucial role they play in tissue maintenance and repair. Considering the number of comorbidities associated with type 2 diabetes mellitus (T2DM), the hypothesis that MSCs mediate these comorbidities via a reduction in their native maintenance and repair activities is an intriguing line of inquiry. Here, it is demonstrated that the number of bone marrow-derived MSCs in people with T2DM was reduced compared to that of age-matched control (AMC) donors and that this was due to a specific decrease in the number of MSCs with osteogenic capacity. There were no differences in MSC cell surface phenotype or in MSC expansion, differentiation, or angiogenic or migratory capacity from donors living with T2DM as compared to AMCs. These findings elucidate the basic biology of MSCs and their potential as mediators of diabetic comorbidities, especially osteopathies, and provide insight into donor choice for MSC-based clinical trials. This study suggests that any role of bone marrow MSCs as a mediator of T2DM comorbidity is likely due to a reduction in the osteoprogenitor population size and not due to a permanent alteration to the MSCs' capacity to maintain tissue homeostasis through expansion and differentiation.

Bone Mineral Is More Heterogeneously Distributed in the Femoral Heads of Osteoporotic and Diabetic Patients: A Pilot Study.

Osteoporosis is associated with systemic bone loss, leading to a significant deterioration of bone microarchitecture and an increased fracture risk. Although recent studies have shown that the distribution of bone mineral becomes more heterogeneous because of estrogen deficiency in animal models of osteoporosis, it is not known whether osteoporosis alters mineral distribution in human bone. Type 2 diabetes mellitus (T2DM) can also increase bone fracture risk and is associated with impaired bone cell function, compromised collagen structure, and reduced mechanical properties. However, it is not known whether alterations in mineral distribution arise in diabetic (DB) patients' bone. In this study, we quantify mineral content distribution and tissue microarchitecture (by µCT) and mechanical properties (by compression testing) of cancellous bone from femoral heads of osteoporotic (OP; n = 10), DB (n = 7), and osteoarthritic (OA; n = 7) patients. We report that though OP cancellous bone has significantly deteriorated compressive mechanical properties and significantly compromised microarchitecture compared with OA controls, there is also a significant increase in the mean mineral content. Moreover, the heterogeneity of the mineral content in OP bone is significantly higher than controls (+25%) and is explained by a significant increase in bone volume at high mineral levels. We propose that these mineral alterations act to exacerbate the already reduced bone quality caused by reduced cancellous bone volume during osteoporosis. We show for the first time that cancellous bone mineralization is significantly more heterogeneous (+26%) in patients presenting with T2DM compared with OA (non-DB) controls, and that this heterogeneity is characterized by a significant increase in bone volume at low mineral levels. Despite these mineralization changes, bone microarchitecture and mechanical properties are not significantly different between OA groups with and without T2DM. Nonetheless, the observed alterations in mineral heterogeneity may play an important tissue-level role in bone fragility associated with OP and DB bone. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Superior patient reported outcome measures reported post Articular Surface Replacement (ASR) revision arthroplasty in the setting of an objective surgical indication.

The Articular Surface Replacement (ASR) hip system displayed unexpectedly high failure rates. All patients who underwent revision arthroplasty at our institution were identified. Indications for revision were classified as objectively identifiable or performed for unexplained pain. Clinical outcomes, post ASR revision, were superior in cases where the aetiology for failure was identifiable. Pain and function improved reliably when a targeted objective indication was identified pre-revision, but failed to do so in cases of unexplained pain. Surgeons familiar with the results of this study will be empowered to discuss expectations and realistic outcomes with their patients undergoing complex revision arthroplasty cases.

Femoroacetabular impingement treatment using the arthroscopic extracapsular outside-in approach: Does capsular suture affect functional outcome?

BACKGROUND: Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical techniques and instrumentation development. An alternative approach consisting in making a first outside-in longitudinal capsulotomy was described by Laude at the end of the 2000s and is experiencing significant development in France. The clinical results of this technique have rarely been reported and in particular the influence of the repair of the capsule is unknown. Therefore we performed a retrospective case control study aiming to asses: (1) the clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of FemoroAcetabular Impingement (FAI) and (2) the effect of capsular closure on the functional outcome. HYPOTHESIS: We hypothesize that the outside-in extracapsular approach is a safe and efficient technique and the capsular closure at the end of the procedure positively affects the functional outcome. METHODS: A retrospective study was conducted on prospectively collected data of a consecutive series of hip arthroscopies performed for surgical treatment of FAI using the outside-in extracapsular approach. Any complications during follow-up were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Functional outcome was assessed using modified Harris Hip Score (mHHS) and Non-arthritic Hip Score (NAHS). RESULTS: Sixty-four hips in 57 patients operated by a single surgeon between October 2013 and December 2016 were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). As the surgical technique evolved over time, a side-to-side capsular closure was performed at the end of the procedure for 25 hips and the capsule was left open for the remaining 39 patients. Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5±11.0 to 88.1±11.2 for mHHS, 63.1±13.8 to 86.4±13.4 for NAHS. Capsular closure leads to a significantly improved clinical outcome: gain in mHHS: 25.8±2.3 vs. 20.6±1.9 (p≤0.044), gain in NAHS: 26.1±2.5 vs. 19.6±2.1, (p=0.023). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented in the group "capsule left open". CONCLUSION: Hip arthroscopy in the management of FAI with an extraarticular starting point (outside-in) is a safe technique with functional results and postoperative morbidity comparable to previously reported techniques. Side-to-side capsular closure at the end of the procedure might positively affect the final functional outcome. LEVELS OF EVIDENCE: III, case control retrospective study.

Cemented Proximal Femoral Replacement for the Management of Non-Neoplastic Conditions: A Versatile Implant but Not Without Its Risks.

BACKGROUND: The demand for revision arthroplasty continues to grow. Proximal femoral bone loss poses a significant challenge to surgeons and proximal femoral replacements (PFRs) are one option to address this problem. The aim of our study is to assess the reoperation, complication, and mortality rates following PFR for treatment of non-neoplastic conditions. METHODS: A retrospective observational study was conducted of a consecutive group of patients treated with a PFR for non-neoplastic conditions between 2010 and 2018. Mortality was confirmed using the Irish national death events publication service. RESULTS: Over the 8-year study period, 79 PFRs in 78 patients were performed. Mean age of patients was 78.3 years (standard deviation 11.9), of which 37.2% were male. Periprosthetic fracture was the most common indication for PFR (63.3%). The 30-day mortality rate was 7.6% (6 patients), of which bone cement implantation syndrome occurred in 4 patients. One-year mortality was 12.7%. Complications occurred in 22.8%. CONCLUSION: A cemented PFR is a versatile prosthesis in the armamentarium of a revision arthroplasty surgeon that allows immediate full weight-bearing. However, it may appropriately be considered a last resort procedure that poses specific risks that must be explained to patients and family. We present the short-term outcomes on one of the largest series of PFR to date.