Ultrasound supports clinical decision-making in determining the Sanders' skeletal maturity score of the hand.

PURPOSE: The Sanders Scoring System has revolutionized the way we assess the remaining growth potential of the skeleton. However, because it involves radiation exposure, it must be used with caution in children. The purpose of the study was to evaluate whether the Sanders skeletal maturity score (SMS) could be accurately determined using ultrasound (U). METHODS: We took radiographs (R) of the hand and performed U of the thumb and index finger in 115 patients between six and 19 years of age who were undergoing treatment for scoliosis or limb deformities. Paediatric orthopaedic surgeons, a paediatrician, and a paediatric radiologist were evaluated the blinded images. Those classified images are based on the SMS and the Thumb Ossification Composite Index (TOCI). RESULTS: Intrarater reliability was high for SMS and slightly weaker for TOCI, but still significant. Interrater reliability was clear for R and weaker for U in both staging systems. Ultimately, SMS 3 and 7 achieved the highest percentage of concordance (P) of 71.7% and 66.0%, respectively, when U was performed. Combining the clinically relevant groups of SMS 3&4 and SMS 7&8 also significantly increased peak scores (SMS 3 and 4 P = 76.7%; SMS 7 and 8 P = 79.7%). The probabilities of peak scores were significantly weaker when the TOCI score was examined. CONCLUSION: Our study shows that U can be used effectively especially to measure stages 3 and 4 and stages 7 and 8 of SMS. The U method is easy to use and therefore may offer advantages in clinical practice without the need for radiation exposure.

The Effect of chemo- and radiotherapy on tumor necrosis in soft tissue sarcoma- does it influence prognosis?

BACKGROUND: Soft tissue sarcomas (STSs) are a heterogeneous group of tumors. Wide surgical resection is standard, often combined with neoadjuvant chemotherapy, radiotherapy, or both. Studies have shown the predictive value of tumor necrosis in bone sarcoma (BS); however, the role of necrosis in STS after neoadjuvant therapies is still unclear. This study aimed to investigate the role of chemo- and radiotherapy in the formation of tumor necrosis and to evaluate the influence of tumor necrosis on overall survival and local recurrence-free survival. Data from BS patients and patients who did not receive neoadjuvant therapy were compared. METHODS: A total of 779 patients with STS or BS were treated surgically. In all patients, tumor-specific factors such as type, size, or grading and the type of adjuvant therapy were documented. Local recurrence (LR), the diagnosis of metastatic disease, and survival during follow-up were evaluated. RESULTS: A total of 565 patients with STS and 214 with BS were investigated. In STS, 24.1% G1 lesions, 34.1% G2 lesions, and 41.8% G3 lesions were observed. Two hundred twenty-four of the patients with STS and neoadjuvant therapy had either radiotherapy (RTx) (n = 80), chemotherapy (CTx) (n = 93), or both (n = 51). Three hundred forty-one had no neoadjuvant therapy at all. In STS, tumor necrosis after neoadjuvant treatment was significantly higher (53.5%) than in patients without neoadjuvant therapy (15.7%) (p < 0.001). Patients with combined neoadjuvant chemo-/radiotherapy had substantially higher tumor necrosis than those with radiotherapy alone (p = 0.032). There was no difference in tumor necrosis in patients with combined chemo-/radiotherapy and chemotherapy alone (p = 0.4). The mean overall survival for patients with STS was 34.7 months. Tumor necrosis did not influence survival in a subgroup of G2/3 patients. In STS with no neoadjuvant therapy and grading of G2/3, the correlation between necrosis and overall survival was significant (p = 0.0248). There was no significant correlation between local recurrence (LR) and necrosis. CONCLUSION: STS shows a broad spectrum of necrosis even without neoadjuvant chemo- or radiotherapy. After CTx or/and RTx necrosis is enhanced and is significantly pronounced with a combination of both. There is a trend toward higher necrosis with CTx than with RTx. Grading substantially influences the necrosis rate, but necrosis in soft-tissue sarcoma following neoadjuvant therapy does not correlate with better survival or a lower local recurrence rate, as in bone sarcomas.

Refusal of Adjuvant Therapies and Its Impact on Local Control and Survival in Patients with Bone and Soft Tissue Sarcomas of the Extremities and Trunk.

BACKGROUND: In soft tissue or bone sarcomas, multimodal therapeutic concepts represent the standard of care. Some patients reject the therapeutic recommendations due to several reasons. The aim of this study was to assess the impact of that rejection on both prognosis and local recurrence. METHODS: Between 2012 and 2019, a total of 828 sarcoma patients were surgically treated. Chemotherapy was scheduled as a neoadjuvant, and adjuvant multi-agent therapy was performed following recommendations from an interdisciplinary tumor board. Radiotherapy, if deemed appropriate, was administered either in a neoadjuvant or an adjuvant manner. The recommended type of therapy, patient compliance, and the reasons for refusal were documented. Follow-ups included local recurrences, diagnosis of metastatic disease, and patient mortality. RESULTS: Radiotherapy was recommended in 407 (49%) patients. A total of 40 (10%) individuals did not receive radiation. A reduction in overall survival and local recurrence-free survival was evident in those patients who declined radiotherapy. Chemotherapy was advised for 334 (40%) patients, 250 (75%) of whom did receive all recommended cycles. A total of 25 (7%) individuals did receive a partial course while 59 (18%) did not receive any recommended chemotherapy. Overall survival and local recurrence-free survival were reduced in patients refusing chemotherapy. Overall survival was worst for the group of patients who received no chemotherapy due to medical reasons. Refusing chemotherapy for non-medical reasons was seen in 8.8% of patients, and refusal of radiotherapy for non-medical reasons was seen in 4.7% of patients. CONCLUSIONS: Divergence from the advised treatment modalities significantly impacted overall survival and local recurrence-free survival across both treatment modalities. There is an imperative need for enhanced physician-patient communication. Reducing treatment times, as achieved with hypofractionated radiotherapy and with therapy in a high-volume sarcoma center, might also have a positive effect on complying with the treatment recommendations.

Muscle forces acting on the greater trochanter lead to a dorsal warping of the apophyseal growth plate.

The apophyseal growth plate of the greater trochanter, unlike most other growth plates of the human body, exhibits a curved morphology that results in a divergent pattern resembling an open crocodile mouth on plain antero-posterior radiographs. To quantify the angular alignment of the growth plate and to draw conclusions about the function of the muscles surrounding it, we analyzed 57 MRI images of 51 children and adolescents aged 3-17 years and of six adults aged 18-52 years. We measured the angulation of the plate relative to the horizontal plane (AY angle) and the trajectories of the muscles attaching to the greater trochanter of the proximal femur. From anterior to posterior, the AY angle shows a decrease of 33.44°. In the anterior third, the cartilage is angled at a mean of 51.64°, and in the posterior third, the mean angulation is 18.6°. This indicates that the cartilage in the anterior region of the greater trochanteric apophysis is subject to more vertically oriented force vectors compared to the posterior region, as the growth plates align perpendicular to the force vectors acting on them. Combining the measured muscle trajectories with the physiological cross-sectional areas (PCSA) available from the literature revealed that, in addition to the known internal and external lateral traction ligament systems, a third, dorsally located traction ligament system exists that may be responsible for the dorsal deformation of the AY angle.

Functional adaptation after femoral intertrochanteric valgus osteotomy in Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease (LCPD) requires individualized treatment in order to regain a functional hip joint. In severe cases, in which a congruent joint cannot be achieved, other options are necessary in order to improve functionality and prevent early osteoarthritis. Therefore, we analysed the clinical and radiologic outcome of 28 patients after valgus osteotomy of the proximal femur (VOF). We examined the range of hip motion, functionality and health-related quality of life (HRQoL) via modified Harris Hip Score (mHHS) and Kidscreen-10. Radiographic analysis contained quantitative and qualitative measurements of hip morphology. In particular, we correlated the results with the change of the pelvic-femoral angle (PFA). PFA was defined as the angle between the anatomical diaphyseal line of the femur and a vertical line through the pelvis. The mean follow-up was 5.5 years. Patients showed high mHHS and good HRQoL postoperatively. An increase in ROM with an improvement of 30.5° abduction and 10.3° internal rotation was evident. PFA correlated with adduction contracture and improved significantly after surgery. In consideration of careful patient selection, VOF showed a positive effect on ROM, pain, HRQoL, radiographic congruence and outcome. We identified the age at surgery and an increasing adduction contracture-objectified by a decreased PFA-as a prognostic factor.

High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF).

The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.

Mismatch between Clinical-Functional and Radiological Outcome in Tibial Plateau Fractures: A Retrospective Study.

BACKGROUND: The evaluation of tibial plateau fractures (TPF) encompasses the assessment of clinical-functional and radiological parameters. In this study, the authors aimed to investigate the potential correlation between these parameters by utilizing both the clinical-functional and the modified radiological Rasmussen score. METHODS: In this retrospective monocentric study conducted at a level-I trauma center, patients who underwent surgery between January 2014 and December 2019 due to a TPF were included. The clinical-functional Rasmussen score prior to the injury, at 1-year postoperatively, and during the last follow-up (minimum 18 months) was assessed using a standardized questionnaire. Additionally, the modified radiological Rasmussen score was determined at the 1-year postoperative mark using conventional radiographs in two planes. RESULTS: A total of 50 patients were included in this study, comprising 40% (n = 20) men, and 60% (n = 30) women, with an average age of 47 ± 11.8 years (range 26-73 years old). Among them, 52% (n = 26) had simple fractures (classified according to Schatzker I-III), while 48% (n = 24; according to Schatzker IV-VI) had complex fractures. The mean follow-up was 3.9 ± 1.6 years (range 1.6-7.5 years). The functional Rasmussen score assessed before the injury and at follow-up showed an "excellent" average result. However, there was a significant difference in the values of complex fractures compared to before the injury. One year postoperatively, both the clinical-functional score and the modified radiological score demonstrated a "good" average result. The "excellent" category was more frequently observed in the functional score, while the "fair" category was more common in the radiological score. There was no agreement between the categories in both scores in 66% of the cases. CONCLUSIONS: The data from this retrospective study demonstrated that patients with TPF are able to achieve a nearly equivalent functional level in the medium-term after a prolonged recovery period, comparable to their pre-injury state. However, it is important to note that the correlation between clinical-functional and radiological parameters is limited. Consequently, in order to create prospective outcome scores, it becomes crucial to objectively assess the multifaceted nature of TPF injuries in more detail, both clinically and radiologically.

Virtual reality in managing Complex Regional Pain Syndrome (CRPS): a scoping review.

Background: Complex Regional Pain Syndrome (CRPS) is a severe pain disorder that does not yet have a specific treatment. Patients with CRPS not only suffer from a wide range of symptoms that affect their quality of life but also present psychological affections to the way they see their body and specifically their affected limb. Virtual Reality (VR) modalities have become a targeted treatment for chronic pain and in the case of CRPS, may be a valuable approach to the mechanisms that affect these patients. Objectives: Using the PRISMA Scoping Review guidelines, we intend to uncover the key information from the studies available about VR modalities in the treatment of CRPS. We focus on the improvement of pain levels, body perception disturbances (BPD), and limb movement/daily function. Results: Our search strategy resulted in 217 articles from PubMed. Twenty were assessed for eligibility and seven were included in the final qualitative synthesis. Of these seven articles, we included a clinical trial, three pilot studies, a blinded randomized controlled trial, a crossover double-blind trial, and a randomized controlled trial. These studies provide important subjective patient findings, along with some statistically significant results in the experiences of VR therapies modulating pain, BPD, and improving limb movement/daily function. However, not all the studies included statistical analysis, and there are contradicting data found from some patients that did not perceive any improvement from VR therapies. Conclusions: We describe the results found in 7 articles that focus on the treatment of CRPS with VR modalities. Overall, the articles have various limitations, but the strategies related to immersive virtual reality, cardiac signaling, body switching and limb modulation have shown the most promising results for pain reduction and BPD improvement. These strategies reflect on pathophysiological mechanisms that are hypothesized to be affected in CRPS patients leading to the chronic pain and BPD that they experience. Not much evidence was found for improvement in limb movement and daily function. This review is a pathway for future studies on this topic and a more extensive data synthesis when more information is available.

Accuracy of Positioning and Risk Factors for Malpositioning Custom-Made Femoral Stems in Total Hip Arthroplasty-A Retrospective Multicenter Analysis.

Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems.

Zinc-Doped Bioactive Glass/Polycaprolactone Hybrid Scaffolds Manufactured by Direct and Indirect 3D Printing Methods for Bone Regeneration.

A novel organic-inorganic hybrid, based on SiO2-CaO-ZnO bioactive glass (BG) and polycaprolactone (PCL), associating the highly bioactive and versatile bioactive glass with clinically established PCL was examined. The BG-PCL hybrid is obtained by acid-catalyzed silica sol-gel process inside PCL solution either by direct or indirect printing. Apatite-formation tests in simulated body fluid (SBF) confirm the ion release along with the hybrid's bone-like apatite forming. Kinetics differ significantly between directly and indirectly printed scaffolds, the former requiring longer periods to degrade, while the latter demonstrates faster calcium phosphate (CaP) formation. Remarkably, Zn diffusion and accumulation are observed at the surface within the newly formed active CaP layer. Zn release is found to be dependent on printing method and immersion medium. Investigation of BG at the atomic scale reveals the ambivalent role of Zn, capable of acting both as a network modifier and as a network former linking the BG silicate network. In addition, hMSCs viability assay proves no cytotoxicity of the Zn hybrid. LIVE/DEAD staining demonstrated excellent cell viability and proliferation for over seven weeks. Overall, this hybrid material either non-doped or doped with a metal trace element is a promising candidate to be translated to clinical applications for bone regeneration.

The Direct Anterior Approach (DAA) as a Standard Approach for Total Hip Arthroplasty (THA) in Coxa Profunda and Protrusio Acetabuli? A Radiographic Analysis of 188 Cases.

INTRODUCTION: The direct anterior approach (DAA) represents a well-recognized soft tissue sparing technique for primary total hip arthroplasty (THA). The feasibility and suitability of the DAA in cases of complex acetabular deformities, namely coxa profunda (CP) and protrusio acetabuli (PA), remain to be determined. METHODS: A total of 188 cases of CP (100 cases) and PA (88 cases) hips undergoing primary THA via the DAA were retrospectively analyzed. Surgical and radiographic parameters were evaluated and potential complications were assessed. Finally, successful implantation was defined if surgical and radiographic parameters were well within established values of non-complex primary THA. RESULTS: In 159 hips, the medial border of the acetabular component was transferred laterally to the ilioischial line, corresponding to a fully treated acetabular protrusion. In 23 (12.23%) cases, mild, and in 5 (2.66%) cases, moderate residual acetabular protrusion remained after THA. Postoperatively, 11.40% (PA group) and 9.00% (CP group) had a leg length discrepancy (LLD) greater than 10 mm. The mean operative time was significantly less than 60 min. A linear relationship between the BMI and operative time was observed, with an additional 0.9 min of operative time per BMI unit. Overall, complications were rare and did not differ between the two groups. CONCLUSION: The results of this study suggest that the DAA is a suitable approach for primary THA in patients with coxa profunda and acetabular protrusion if performed by experienced surgeons familiar with the DAA. Obese patients with acetabular protrusion may pose a significant limitation to the DAA and caution should be advised in cases of obesity.

Efficacy of post-operative partial weight-bearing after total knee arthroplasty - a prospective observational trial.

PURPOSE: There is little evidence proving the concept of partial weight-bearing to be efficient and feasible. Using insole pressure measurement systems, this study aimed to explore the compliance to prescribed weight-bearing restrictions after total knee arthroplasty (TKA). METHODS: 50 patients after TKA were recruited in a prospective manner. They were advised to limit weight-bearing of the affected limb to 200 N. True load was measured via insole force-sensors on day one after surgery (M1) and before discharge (M2). Compliance to the rehabilitation protocol was the primary outcome parameter. RESULTS: At M1 and M2 compliance to the rehabilitation protocol was 0% und 2%, respectively. 84% (M1) and 90% (M2) of patients overloaded the affected limb during every step. The affected limb was loaded with 50% ± 14% (M1) and 57% ± 17% (M2) of body weight. Patients older than 65 loaded the affected limb on average 17% (M1) and 34% (M2) more than their younger counterparts did. This difference was even more pronounced when walking stairs up (49% increase on average) and down (53% increase on average). CONCLUSION: Surgeons must take into consideration that the ability to maintain partial weight-bearing after TKA is highly dependent on the age of the patient and the achievable load reduction is determined by the patient's body weight.

Conversion total hip arthroplasty following proximal femur fracture: A retrospective analysis.

BACKGROUND: The incidence of conversion total hip arthroplasty (cTHA) following reduction and fixation for proximal femur fractures will increase in parallel to the aging population worldwide. OBJECTIVE: The goal of this study is to report the frequency of bacterial detection and the outcome of cTHA at the authors' institution and to analyze preoperative factors that correlate with higher rates of bacterial growth and septic revision. METHODS: 48 patients who had been converted to THA after osteosynthesis of a proximal femur fracture either by a one- or two-stage procedure were included. Septic failure rate and the frequency of bacterial detection at the time of fixation device removal were calculated. The influence of different preoperative factors was examined by the odds ratio. A receiver operating characteristic curve of c-reactive protein (CRP) for detection of bacterial growth at the time of fixation device removal was calculated. RESULTS: 18.8% patients showed positive bacterial cultures, with Staph. epidermidis being the most frequent pathogen (33.3%). Septic failure after cTHA occurred in 4.2%. Fixation with cephalomedullary nails and complications with the internal fixation showed higher odds for bacterial growth at time of cTHA. CRP for predicting bacterial growth had an area under the curve of 0.661. Implant survival was worse when temporary spacers were used. CONCLUSION: Bacterial detection rate at the time of cTHA is high, whereas septic failure rates are low. Isolated evaluation of inflammatory blood markers without other diagnostic modalities for infection is not decisive and does not justify a two-stage approach with implantation of a temporary spacer.

Intrainstitutional Changes of the Treatment of Supracondylar Humerus Fracture in Children over a Period of 9 Years.

To assess changes in treatment modalities for supracondylar humerus fractures (SCHFs) at a large pediatric university hospital, we analyzed patient data from 2014 to 2022. A total of 233 SCHFs treated surgically at our hospital were included. To evaluate postoperative outcome and quality of life, DASH and EuroQol-5D-Y questionnaires were sent to patients. In addition to a significant fluctuation in fracture severity, we found an increase in training interventions (more surgeries were performed by trainees) and a significant decrease in surgery times after 2016. From 2020, there was a significant shift in the type of surgical method away from closed reduction with elastic stable intramedullary nailing (ESIN) and towards closed reduction and crossed K-wire osteosynthesis (CRK). Surgeries performed in the morning and evening hours increased, while those performed in the afternoon and after midnight decreased. After a mean follow-up of 4 years, there was no difference in elbow function between ESIN and open reduction and K-wires (ORK). Treatment with ESIN was equivalent to ORK in terms of function, at least in the medium-term follow-up. In summary, the combination of shifting treatment from SCHF to daytime hours, increasing trainee participation and using cross K-wire fixation instead of ESIN had no negative impact on surgery times. In our setting, these measures have reduced resource utilization and increased efficiency without compromising patient care.

Does Posterior Tibial Slope Influence Knee Kinematics in Medial Stabilized TKA?

BACKGROUND: During total knee arthroplasty (TKA), one of the key alignment factors to pay attention to is the posterior tibial slope (PTS). The PTS clearly influences the kinematics of the knee joint but must be adapted to the coupling degree of the specific TKA design. So far, there is hardly any literature including clear recommendations for how surgeons should choose the PTS in a medial stabilized (MS) TKA. The aim of the present study is to investigate the effects of different degrees of PTS on femorotibial kinematics in MS TKA. MATERIALS AND METHODS: An MS TKA was performed in seven fresh-frozen human specimens successively with 0°, 3°, and 6° of PTS. After each modification, weight-bearing deep knee flexion (30-130°) was performed, and femorotibial kinematics were analyzed. RESULTS: A lateral femoral rollback was observed for all three PTS modifications. With an increasing PTS, the tibia was shifted more anteriorly on the lateral side (0° PTS anterior tibial translation -9.09 (±9.19) mm, 3° PTS anterior tibial translation -11.03 (±6.72) mm, 6° PTS anterior tibial translation 11.86 (±9.35) mm). No difference in the tibial rotation was found for the different PTS variants. All PTS variants resulted in internal rotation of the tibia during flexion. With a 3° PTS, the design-specific medial rotation point was achieved more accurately. CONCLUSIONS: According to our findings, we recommend a PTS of 3° when implanting the MS prosthesis used in this study.

Resource Consumption and Remuneration Aspects in Navigated Screw Fixation Procedures with or without Additional Sacroplasty for Fragility Fractures of the Sacrum-A Prospective Clinical Study.

Surgical treatment for sacral fragility fractures using navigation-assisted screw fixation (NSF) is a modern, technically demanding procedure. Additional sacroplasty (ASP) has been shown to provide only insignificant clinical benefits for patients. This investigation highlights procedural economic aspects and evaluates results with regard to resource scarcity in order to be able to decide, whether ASP has a justification in NSF procedures beyond clinical aspects. From February 2011 to May 2017, all individuals with sacral fragility fractures surgically treated using 3D-fluoroscopy for NSF (n = 26) or NSF + ASP (n = 26) were enrolled. Outcome parameters were operative time, 3D-/2D-radiation dose, 2D-fluoroscopy time, material costs and reimbursement. In the two groups, a total of 52 individuals with 124 fragility fracture sites in sacral vertebrae I and II were surgically treated with similar numbers of screws inserted (p ≈ 0.679) requiring similar 3D- (p ≈ 0.546) and 2D-fluoroscopy radiation doses (p ≈ 0.236). In procedures with ASP, average 2D-fluoroscopy time (46.6 s vs. 32.7 s, p ≈ 0.004), and mean surgical duration (119 min vs. 96 min, p ≈ 0.011) were significantly longer. Mean implant costs (EUR 668.68 vs. EUR 204.34, p < 0.001), and reimbursement (EUR 8416.01 vs. EUR 6584.49, p ≈ 0.006) were significantly higher. Although comparison of costs and reimbursements indicated a positive financial balance, profitability was not confirmed, because financial expense for extended operative time prevented an economic advantage of procedures with ASP in this investigation. A formula was developed based on presented study data to allow similar economical decisions in other health care systems or institutions with differing resource costs.

Acetabular defect management and revision arthroplasty via the direct anterior approach.

OBJECTIVE: Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. INDICATIONS: Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. CONTRAINDICATIONS: Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. SURGICAL TECHNIQUE: Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. A stepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a "tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. POSTOPERATIVE MANAGEMENT: Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6 weeks. RESULTS: Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.

Proximal femoral replacement using the direct anterior approach to the hip.

OBJECTIVE: Proximal femoral replacement (PFR) is a salvage procedure originally developed for reconstruction after resection of sarcomas and metastatic cancer. These techniques can also be adapted for the treatment of non-oncologic reconstruction for cases involving massive proximal bone loss. The direct anterior approach (DAA) is readily utilized for revision total hip arthroplasty (THA), but there have been few reports of its use for proximal femoral replacement. INDICATIONS: Aseptic, septic femoral implant loosening, periprosthetic femoral fracture, oncologic lesions of the proximal femur. The most common indication for non-oncologic proximal femoral placement is a severe femoral defect Paprosky IIIB or IV. CONTRAINDICATIONS: Infection. SURGICAL TECHNIQUE: In contrast to conventional DAA approaches and extensions, we recommend starting the approach 3 cm lateral to the anterior superior iliac spine and performing a straight incision directed towards the fibular head. After identification and incision of the tensor fasciae lata proximally and the lateral mobilization of the iliotibial tract distally, the vastus lateralis muscle can be retracted medially as far as needed. Special care should be taken to avoid injuries to the branches of the femoral nerve innervating the vastus lateralis muscle. If required, the distal extension of the DAA can continue all the way to the knee to allow implantation of a total femoral replacement. The level of the femoral resection is detected with an x­ray. In accordance with preoperative planning, the proximal femur is resected. Ream and broach the distal femoral fragment to the femoral canal. With trial implants in place, leg length, anteversion of the implant and hip stability are evaluated. It is crucial to provide robust reattachment of the abductor muscles to the PFR prosthesis. Mesh reinforcement can be used to reinforce the muscular attachment if necessary. POSTOPERATIVE MANAGEMENT: We typically use no hip precautions other than to limit combined external rotation and extension for 6 weeks. In most cases, full weight bearing is possible after surgery. RESULTS: A PFR was performed in 16 patients (mean age: 55.1 years; range 17-84 years) using an extension of the DAA. The indication was primary bone sarcoma in 7 patients, metastatic lesion in 6 patients and massive periprosthetic femoral bone loss in 3 patients. Complications related to the surgery occurred in 2 patients (both were dislocation). Overall, 1 patient required reoperation and 1 patient died because of his disease. Mean follow-up was 34.5 months.