Efficacy of Bisphosphonates in Total Hip Arthroplasty Patients: Systematic Review and Meta-Analysis.

The scientific literature suggests that, if periprosthetic osteolysis (PPO) is not treated, it may have a negative impact on the results of a total hip replacement and possibly result in failure. This systematic review aimed to determine the efficacy of using bisphosphonates preventatively to limit PPO after a total hip arthroplasty (THA). METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A PICOS template was developed to ensure a structured approach. A search for relevant studies was performed across four databases, including Pubmed, Scopus, Embase, and Cochrane. They were all last searched on March 1st and were assessed using the Cochrane risk of bias tool for randomised studies. RESULTS: The final analysis included seven studies with a total of 126 study group participants and 144 control group participants. The studies looked at Bony Mass Density in terms of bone loss on Gruen's femoral zones after THA in a bisphosphonate (treatment) and control group (placebo/no treatment). The analysis revealed a statistically significant difference (p < 0.05) in favour of the bisphosphonate group in many of the included studies at 6, 12, and 24 postoperative months. CONCLUSIONS: This systematic review and meta-analysis, using the most recent applicable studies, showed the efficacy of bisphosphonates in limiting periprosthetic osteolysis after THA in a period between 6 and 24 postoperative months. Future studies should focus increasing group sizes and collecting results beyond the 2-year mark.

Leg length discrepancy after total hip arthroplasty performed by direct anterior approach: a systematic review comparing surgical approaches and strategies for prevention.

Purpose: Leg length discrepancy (LLD) is a common complication following total hip arthroplasty (THA). The direct anterior approach (DAA) for THA is gaining popularity due to its advantages, but there is limited research on the incidence and size of LLD. This systematic review aims to explore the differences in LLD between DAA and other approaches, as well as the techniques to control LLD in DAA. Methods: A comprehensive literature search was conducted to identify relevant studies comparing THA by DAA with other surgical approaches and investigating methods to control LLD in DAA, following PRISMA guidelines and a priori registration on PROSPERO (CRD42023412644). The quality of the included studies was assessed. Data on preoperative and postoperative LLD and other relevant outcomes were extracted and analyzed descriptively. Results: In total, 29 studies were included in this systematic review. The majority (86%) were classified as level IV evidence. Comparisons between DAA and posterior approach (PA) or anterolateral approach (ALA) showed DAA had lower rates of LLD >10 mm compared to PA and ALA. Different pre- and intra-operative techniques were evaluated, but no consensus on the best method for preventing LLD in DAA was reached. Conclusion: DAA shows comparable or superior results in the prevention of LLD compared to other surgical approaches. Supine patient placement, direct leg measurement, and the use of IF contribute to these outcomes. Intraoperative fluoroscopy with a grid and preoperative planning offers a good option, especially for training purposes, but its role in preventing LLD by experienced DAA surgeons needs further investigation.

Anterior Minimally Invasive Approach (AMIS) for Total Hip Arthroplasty: Analysis of the First 1000 Consecutive Patients Operated at a High Volume Center.

(1) Background: Direct anterior approach (DAA) has recently acquired popularity through improvements such as the anterior minimally invasive surgical technique (AMIS). This retrospective study examines the first 1000 consecutive THAs performed utilizing the AMIS approach in a high-volume center between 2012 and 2017. (2) Methods: 1000 consecutive THAs performed at a single institution utilizing the AMIS approach were retrospectively analyzed with a minimum five-year follow-up. Full evaluation of demographic information, clinical parameters, intraoperative complications, and radiological examinations are reported. (3) Results: Overall complication rate was 9.4% (94/1000), including 8 dislocations, 57 femoral-cutaneous nerve injuries, 12 intraoperative femoral fractures, 9 infections and 8 leg length discrepancy. Implant survival rates were 98.5% at 1 year, 97.5% at 3 years, 97% at 5 years, and 95.3% at 7 years. Causes of failure included periprosthetic fractures (0.8%), implant dislocations (0.6%), septic loosening (0.5%), aseptic mobilizations (0.2%), and symptomatic limb length discrepancies (0.2%). (4) Conclusions: Controversies persist around the direct anterior approach (DAA) for THA, primarily regarding the increased complications rate during the learning curve. However, this study advocates for widespread adoption of the DAA approach. The results demonstrate acceptable complication rates and remarkable functional outcomes, affirming its viability in the broader orthopedic patient population.

Direct Anterior Approach in Total Hip Arthroplasty for Severe Crowe IV Dysplasia: Retrospective Clinical and Radiological Study.

Background and Objectives: total hip arthroplasty (THA) for Crowe IV hip dysplasia poses challenges due to severe leg shortening, muscle retraction and bone stock issues, leading to an increased neurological complication, and revision rate. The direct anterior approach (DAA) is used for minimally invasive THA but its role in Crowe IV dysplasia is unclear. This retrospective study examines if DAA effectively restores hip biomechanics in Crowe IV dysplasia patients with <4 cm leg length discrepancy, managing soft tissue and yielding functional improvement, limb length correction, and limited complications. Materials and Methods: 19 patients with unilateral Crowe IV hip osteoarthritis and <4 cm leg length discrepancy undergoing DAA THA were reviewed. Surgery involved gradual soft tissue release, precise acetabular cup positioning, and stem placement without femoral osteotomy. Results: results were evaluated clinically and radiographically, with complications recorded. Follow-up revealed significant Harris Hip Score and limb length discrepancy improvements. Abductor muscle insufficiency was present in 21%. The acetabular component was accurately placed, centralizing the prosthetic joint's rotation. Complications occurred in 16% of cases, including fractures, nerve issues, and infection. DAA in THA showcased positive outcomes for hip function, limb length, and biomechanics in Crowe IV dysplasia. Conclusions: the technique enabled accurate cup positioning and rotation center adjustment. Complications were managed well without implant revisions. DAA is a viable option for Crowe IV dysplasia, restoring hip function, biomechanics, and reducing limb length discrepancy. Larger, longer studies are needed for validation.

Long-term survival and complication rate of cementless prosthetic stems in primary total hip arthroplasty categorized by types according to Mont classification: a regional registry-based study on 53,626 implants.

INTRODUCTION: The purpose of this retrospective registry-based study is to assess survival and causes of failure of cementless stem implants used in total hip arthroplasty (THAs), to ascertain if there are differences when these are categorized according to the six types described by Mont. METHODS: Data collected from the regional registry regarding all primary THAs performed from 2000 to 2019 were analyzed. Femoral prosthetic stems were divided into the six types of Mont classification. For each stem type, number of implants, survival and causes of failure were evaluated and compared. RESULTS: The most frequently implanted stem type was the 3c type (53.4%). Type 1 had the lowest stem failure rate (1.6%), and type 6 showed the highest (3.9%). Periprosthetic fracture was the most frequent complication in type 6, accounting for 34.5% of failures. Aseptic loosening was the main complication in type 2 stems, accounting for 36.4% of failures. Pairwise comparisons showed significant higher survival of type 1 compared to type 3c (p = 0.000026) and type 6 (p = 0.000076), and between type 3a compared to type 3c (p = 0.03) and type 6 (p = 0.026). CONCLUSION: Significant variations in implant survival rates were found among the six Mont-types of cementless stems. These findings emphasize the paramount importance of stem design and fixation area in determining long-term survival, providing a guidance for orthopedic surgeons in the selection of the most appropriate stem for primary THA, contributing to our understanding of cementless stem performance, presenting invaluable insights to further improve patient outcomes in THA surgery.

Role of biophysical stimulation in multimodal management of vertebral compression fractures.

Raised life expectancy and aging of the general population are associated with an increased concern for fragility fractures due to factors such as osteoporosis, reduced bone density, and an higher risk of falls. Among these, the most frequent are vertebral compression fractures (VCF), which can be clinically occult. Once the diagnosis is made, generally thorough antero-posterior and lateral views of the affected spine at the radiographs, a comprehensive workup to assess the presence of a metabolic bone disease or secondary causes of osteoporosis and bone frailty is required. Treatment uses a multimodal management consisting of a combination of brace, pain management, bone metabolism evaluation, osteoporosis medication and has recently incorporated biophysical stimulation, a noninvasive technique that uses induced electric stimulation to improve bone recovery through the direct and indirect upregulation of bone morphogenic proteins, stimulating bone formation and remodeling. It contributes to the effectiveness of the therapy, promoting accelerated healing, supporting the reduction of bed rest and pain medications, improving patients' quality of life, and reducing the risk to undergo surgery in patients affected by VCFs. Therefore, the aim of this review is to outline the fundamental concepts of multimodal treatment for VCF, as well as the present function and significance of biophysical stimulation in the treatment of VCF patients.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review.

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Which Patients with Chronic Periprosthetic Joint Infection Are Less Suitable to Successful Two Stage Exchange Arthroplasty Surgery? A Retrospective Clinical Trial.

BACKGROUND: Two-stage exchange (TSE) arthroplasty is currently considered the gold standard for chronic periprosthetic joint infections (PJIs), despite a failure rate reported in up to 10% of patients. Little is known about the risk factors that may compromise successful TSE arthroplasty management in such patients. The main purpose of the current study was to highlight the potential risk factors of patients with chronic PJIs after THA managed by implant removal, outlining the differences between reimplanted patients and those that were never reimplanted because of a non-eradicated infection. METHODS: We conducted a retrospective observational study of patient candidates for TSE arthroplasty surgery, managed at the authors' institution, over a four-year timeframe. The data were retrieved from the hospital's information database. The enrolled population was divided into two Groups: A, reimplanted; B, non-reimplanted because of a non-eradicated infection within one year. For each Group, demographic information, PJI-related risk factors, type of pathogen and presence of single or polymicrobial infection, were collected and analyzed. RESULTS: In total, 21 patients were included in the study, 14 patients in Group A and 7 in Group B. Major Depression (p = 0.049) and polymicrobial infection (p = 0.04) were more commonly observed in patients that were not reimplanted in the study period. No differences between the two groups were observed when other characteristics were compared. CONCLUSIONS: Patients with major depression, or those hosting polymicrobial periprosthetic hip infections, are more susceptible to failure of TSE arthroplasty procedures for chronic PJIs, hampering THA reimplantation. Current findings may drive further research and contribute to the understanding of the role of these risk factors in chronic PJI patients.

What is the middle term survival of reverse shoulder arthroplasty? A retrospective observational registry-based study.

PURPOSE: The use of reverse total shoulder arthroplasty has increased over the last decade. Like any other implant it is associated with complications sometimes leading to revision. We carried out a registry-based study in order to find possible risk factors associated with the need of revision surgery. METHODS: The RIPO registry was analyzed from July 2008 to December 2018 collecting available data. Two groups (degenerative or fracture) were formed and compared to determine possible risk factors difference in revision surgery. RESULTS: A total of 7,966 shoulder prosthesis were implanted. There was a 1.5% intra or peri-operative complication rate. The revision rate was 4.0% at a mean follow-up of 4.4 years. A total of 3,073 reverse total shoulder prosthesis were implanted and available for follow-up. An increase of revision rate (the most frequent causes being aseptic loosening, infection and instability) was found in patients younger than 65 years and in male patients. Two groups were then formed on the basis of the primary diagnosis: osteoarthritis and proximal humerus fracture. Comparison between the two groups showed an increase in instability requiring revision in the fracture group. CONCLUSION: Reverse shoulder prosthesis is a valid treatment option both in the elective and in the trauma settings, but young and male patients should be informed of the inherently increased risk of revision and prosthesis used in the fracture setting should be evaluated more thoroughly to prevent instability.

Aesthetic Results, Functional Outcome and Radiographic Analysis in THA by Direct Anterior, Bikini and Postero-Lateral Approach: Is It Worth the Hassle?

Total hip arthroplasty (THA) can be performed by several approaches such as direct anterior (DAA), direct lateral (DL) and postero-lateral (PL). Our study was conducted to compare among different approaches, such as DAA, bikini (BK) and PL, the aesthetic impact of the scar, differences in the position of prosthetic components and differences in functional rehabilitation outcomes. Materials and methods: Population, composed by 240 patients, was collected among patients treated for primary total hip arthroplasty (THA) from 1 January 2017 to 31 December 2021 and divided by surgical approach. Of these, 160 female patients were included in the current analysis, leaving 58 DAA, 52 BK patients and 50 PL patients. Demographic and clinical parameters were retrospectively collected: age, BMI, time of surgery, length of stay, Harris Hip Score (HHS) before and after surgery at 6 months and patient, intra/post-surgical complications and Patient and Observer Scar Assessment Scale (POSAS). Results and Discussion: Our results showed a better aesthetical result in BK group compared to DAA group and faster rehabilitation with the DAA compared to PL. Optimal cup positioning was reached both in PL approach and DAA approach. DAA showed no increase in complications compared to PL approach and offered a faster recovery. Bikini approach is an alternative to the standard DAA approach and can be proposed for patients where a better aesthetic result is desired in addition to better functional recover.

Unstable Total Hip Arthroplasty: Should It Be Revised Using Dual Mobility Implants? A Retrospective Analysis from the R.I.P.O. Registry.

Total hip arthroplasty (THA) is one of the most common surgical procedures in orthopedics; however, it is subjected to different kinds of failures, one of them being dislocation. Many different prosthetic designs have been developed to overcome this problem, such as dual mobility coupling. The main purpose of this article is to determine whether there are differences regarding the revision surgery of unstable THA comparing the risk of failure between dual mobility cup (DMC) implants, standard implants, and among different head sizes. A registry-based population study has been conducted by analyzing data collected by the Emilia Romagna Registry of Orthopedic Prosthetic Implants (RIPO), including a total of 253 implants failed for dislocation and instability that were operated on by cup revision surgery between 2000 and 2019. The selected population has been divided into two groups based on the insert type: standard and DMC. The age at revision surgery was significantly lower in the standard cup group with respect to DMC (p = 0.014 t-test), with an average age of 71.2 years (33-96 years range) for the standard cups and 74.8 years (48-92 years range) for the DMC group. The cumulative survival of DMC implants was 82.0% at 5-years, decreasing to 77.5% at a 10-year follow-up, which is not significantly different from standard cups (p = 0.676, Log-Rank test). DMC implants showed a significantly lower risk of re-revision for dislocation compared to standard cups (p = 0.049). Femoral heads ≥36 mm had a higher overall survival compared to smaller femoral heads (p = 0.030). This study demonstrated that DMC or femoral heads ≥36 mm are a valid choice to manage THA instability and to reduce the revision rate for dislocation at a mid-term follow-up; in those selected and targeted patients, these options should be taken into consideration because they are associated with better outcomes.

Cornea verticillata in Fabry disease: a comparative study between slit-lamp examination and in vivo corneal confocal microscopy.

PURPOSE: To compare the diagnostic power of slit-lamp examination with the in vivo corneal confocal microscopy (IVCM) as the gold standard in assessing the presence of corneal epithelial deposits in patients with Fabry disease (FD). METHODS: Fourteen patients with FD (4 males, 10 females; mean age, 46.8 years) and eight healthy controls (4 males, 4 females; mean age, 36.75 years) were included. All subjects underwent slit-lamp examination and IVCM of both central and peripheral corneal quadrants with the Heidelberg Retina Tomograph-III in combination with the Rostock Cornea Module. RESULTS: In patients with FD, 9 of 28 eyes (32%) showed the presence of cornea verticillata at the slit-lamp examination and 25 eyes (89%) showed the presence of epithelial hyper-reflective deposits at the IVCM. Of the 19 eyes negative at the slit-lamp examination, 16 eyes showed the presence of epithelial deposits at the IVCM. Compared with controls, patients with FD had a significantly reduced number, density and length of nerve fibres at the level of corneal sub-basal nerve plexus, but a significantly higher grade of fibres tortuosity. CONCLUSIONS: The slit-lamp examination has a limited diagnostic power in the detection of epithelial deposits in patients with FD when compared with the IVCM. In fact, the slit-lamp examination suffers from a high number of false negative results and, consequently, from a low negative predictive value (16%). IVCM allows the detection of corneal microstructural changes in patients with FD and may represent a reliable tool for the early diagnosis and follow-up of the disease.