Taper-wedge stem suitable for anterior approach total hip arthroplasty: Adequate biomechanical reconstruction parameters and excellent clinical outcome at mid-term follow-up.

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is a less invasive and muscle-sparing approach that seems to improve early function and patient satisfaction. Several studies, however, have reported high complication and revision rates due to the technical difficulties related to the femoral preparation. AIM: To evaluate the usefulness and safety of a new stem equipped with a morphometric design and a size-specific medial curvature in DAA for THA. METHODS: This retrospective study was based on 130 patients that underwent mini-invasive DAA procedures for THA using the Accolade II stem. A total of 144 procedures were included in the assessment, which was based on postoperative complications, survival rates, functional parameters, and patient related outcomes. RESULTS: Overall complications were recorded in 6 procedures (4.2%). There were no complications related to the stem implantation and no intraoperative fractures. Only one patient was revised for deep infection. On radiographs, biomechanical hip reconstruction was satisfactory and no stem showed any subsidence greater than 2 mm. Full osseointegration based on Engh scores was seen in all of the implanted stems. Median Harris hip score at final follow-up was 99 points (range 44-100 points), which resulted excellent in 91.3% of patients. The median values of the osteaorthritis outcome score ranged from 87.5 to 95. CONCLUSION: The mid-term positive outcomes and low complication rate in our consecutive series of patients support the safety and suitability of this new stem design in DAA for THA.

All-arthroscopic Knee Patellofemoral Ligament Repair.

Patellar dislocations are common injuries in the pediatric and adolescent population, with an estimated mean incidence of 42/100,000 person-years. The medial patellofemoral ligament is the most important structure preventing lateral patellar translation, whereas its patellar attachment is frequently damaged after patellar dislocations. This technical note presents an all-arthroscopic medial patellofemoral ligament repair technique suggested after a first episode of patellar dislocation.

Targeting the safe zones for cup position without fluoroscopic guidance in total hip arthroplasty: does the surgical approach affect the outcomes?

BACKGROUND: Proper acetabular cup positioning is crucial for achieving implant longevity and stability in total hip arthroplasty (THA). One of the elements that may affect the accuracy and precision of the positioning of the cup is the type of surgical approach used. This study compares the accuracy and the precision of conventional free-hand acetabular cup positioning relative to different "safe zones" in two groups of patients operated with THA using two different surgical approach. METHODS: Retrospective radiological comparative matched-pair controlled study of two groups of patients operated with primary THA: the first group was operated in supine decubitus with a mini-invasive direct anterior approach (DA group), the second group was operated in lateral decubitus with a conventional posterolateral approach (PL group). Cup inclination and anteversion were assessed using the digital planning software TraumaCad. Cup position in the two groups were compared in terms of accuracy and precision. RESULTS: Forty four patients were enrolled for each group. The DA group showed a less inclined and less anteverted cup compared to the PL group (respectively 38.5 ± 5.2 vs. 49.6 ± 5.6 and 16.2 ± 3.6 vs. 22.9 ± 6.4; p < 0.01). The DA group showed a significantly higher percentage of cups within the "safe zone" in 4 out of 6 reference zones and a significantly lower variance in anteversion (12.96 vs. 40.96, p < .01). There was no difference in the variance for inclination. CONCLUSIONS: Our study found greater accuracy and precision in the positioning of the cup when surgery was performed through a direct anterior approach compared to the posterolateral approach due to the supine position of the patient which allows greater stability of the pelvis during surgery and makes it easier to target the desired angular references for cup positioning.

Fifteen years change in acute management of hip fracture patients: 1-year mortality calls for improvements.

INTRODUCTION: Over the past two decades, the average age of hip fractured patients has increased, patients are increasingly fragile and their management is more complex. Most of the literature suggest that care improvement lowered short-term mortality but there is no clear evidence whether mid- and long-term mortality rates are improving. The aim of this study was to evaluate the variations in comorbidities in hip fractured patients over 15 years, the changes in mortality and identify the predictive factors for mortality for identifying the patients at higher risk. MATERIALS AND METHODS: Hip fractured patients admitted in hospital in 2000-2001 (192 patients) and 2015-2016 (323 patients) were retrospectively reviewed. Demographic, clinical and management data from the two cohorts were compared. Thirty-day and 1-year mortality were calculated and compare between the two cohorts. A multivariate logistic regression model were performed to identify the most significant predictors of mortality. RESULTS: After fifteen years, mean age of hip fracture patients increased by 2.6 years with a 31% increase in comorbidity. The most prevalent comorbidities were hypertension, COPD, diabetes, arrhythmia, renal impairment and dementia. In the 2015-2016 cohort, the age-adjusted mortality at 30 days significantly declined compared to the 2000-2001 cohort (respectively 6.9% vs. 12.5%) but the age-adjusted mortality at 1-year was equivalent. Older age, reduced mobility, higher comorbidity, lateral fractures and male sex were significant risk factors for reduced survival time CONCLUSIONS: After 15 years, there was a significant improvement in 30-days mortality in hip fractured patients despite their increase in comorbidities but this advantage was not observed in 1-year mortality. This suggests the need to implement targeted and longer-term care support for males, older patients and those with greater comorbidities which are at higher risk.

Antero-inferior paralabral cyst of the shoulder: An atypical cause of rapidly evolving axillary and musculocutaneous nerve palsy.

Paralabral cysts of the shoulder are a rare cause of shoulder pain. Their association with neurological symptoms is uncommon. This case report presents an antero-inferior paralabral cyst in a painful atraumatic shoulder causing axillary and musculocutaneous nerve palsy. The patient in the present study showed a rapidly worsening active shoulder function with dull pain in the posterior shoulder and hypoesthesia over the deltoid. Magnetic resonance imaging revealed an antero-inferior paralabral cyst. Electromyography showed a profuse denervation of the deltoid, teres minor and biceps brachii muscles. The patient was diagnosed with a axillary and musculocutaneous nerve compression neuropathy caused by the cyst. Shoulder arthroscopy was performed with the goal of decompressing the cyst and explore the terminal branches of the brachial plexus. During surgery a partial labral tear was detected and anatomically repaired after cyst resection. Exploration of the terminal roots of the plexus brachialis showed the presence of dense fibrotic tissue that was released. Shoulder function recovered completely after surgery. Paralabral cysts are rare and surgical management consists of cyst removal and labral repair. In presence of neurological symptoms exploring the retrocoracoid plexus may be a useful option to check for fibrosis around the nerves that could limit or slow down nerve recovery.

Year to year comparison of 2000-2015 in hip fracture management: same survival rate despite older and more fragile patients.

PURPOSE: The aim of this study was to compare clinical data, comorbidities and survival rates at 30 days and 1 year in two groups with femoral fractures, the first including patients admitted in 2000, and the other including patients admitted in 2015. The hypothesis of the study is that patients admitted in 2015 have more comorbidities and will therefore have a lower survival rate at 30 days and 1 year from trauma. METHODS: Patients admitted to the hospital with proximal femoral fractures in 2000 (90 patients) and 2015 (167 patients) were retrospectively reviewed. The following data were collected: age, gender, source of admission, ASA score, comorbidities, time from admission to surgery and length of hospital stay. The Charlson Comorbidity Index (CCI) score, a measure of comorbidity, and the Nottingham Hip Fracture Score (NHFS), a predictor of 30-day and 1-year mortality after hip fracture, were both calculated. RESULTS: Patients in the 2015 group were older and more institutionalized before fracture (p < 0.05), with a significant increase in Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure and renal impairment. The length of stay was significantly lower in 2015. The NHFS and CCI were significantly higher in 2000. Mortality at 30 days and 1 year did not differ significantly in 2000 when compared to 2015. The CCI had the best predictive ability for mortality in both groups at 30 days and 1 year. CONCLUSIONS: The increase of comorbidities was not found to be correlated to increased mortality. This could be explained by enhanced patient management permitting earlier mobilization and weight bearing.