Femoral head and neck autograft in arthroplasty for developmental dysplasia of the hip: a systematic review of long-term outcomes.

PURPOSE: Total hip arthroplasty (THA) with an acetabular component and an autogenous femoral head graft for acetabular reconstruction in developmental dysplasia of the hip was first described by Harris et al. in 1977. While a number of studies have addressed the aforementioned scenario over the last decades, most lack sufficient numbers and follow-up. As such, we analyzed long-term outcomes of THAs with femoral autograft for arthrosis secondary to hip dysplasia. METHODS: A systematic review was performed using a structured PubMed, Web of Science, Ovid MEDLINE, and Cochrane analysis, based on the PRISMA criteria. All original studies from 1977 to 2022 with a mean follow-up of 10 or more years were included. Methodological Index for Nonrandomized Studies (MINORS) were used for quality assessment. RESULTS: A total of 26 studies with 1316 patients (87% females) undergoing 1543 THAs with femoral autograft (2 times neck graft, 24 times head graft) were included. Mean age was 52 years (range, 28-73) and the mean follow-up was 13 years (range, 9-18). The revision rate was 8.3% (n = 129), and 73% of revisions were for loosening. Rate of infection (0.5%) and dislocations (1%) were low. Radiographic analysis revealed 167 loose acetabular components (11%) and 118 cases of graft resorption (7.6%). Mean Harris Hip Score increased from 42 to 85. Mean MINORS score was 11, and no study was level of evidence I or II. CONCLUSIONS: Femoral autograft with THA may be a viable long-term option for hip reconstruction in developmental dysplasia of the hip. However, moderate loosening rates and low level of evidence must be acknowledged before drawing the final conclusions. LEVEL OF EVIDENCE: Therapeutic Level III.

Modified Anterolateral Minimally Invasive Surgery (ALMIS) for Total Hip Replacement: Anatomical Considerations, Range of Motion and Clinical Outcomes.

Background and Objectives: In the modified anterolateral minimally invasive surgery (ALMIS) for total hip arthroplasty (THA), the intermuscular plane between the tensor fasciae latae and the gluteus maximus (GM) is exposed, while the anterior » of the GM is detached. There are scarce data regarding this surgical approach. The purpose of the present study is to thoroughly describe this approach, encompassing the anatomical background, and to present the results of a retrospective two-center study of 603 patients. Materials and Methods: The present study includes a two-center retrospective observational cohort of 603 patients undergoing the ALMIS technique with minimum 5-year follow-up. Demographics were recorded, while range of motion (ROM) of the hip joint and the Harris Hip Score (HHS) were evaluated preoperatively, at 1, 3 and 12 months postoperatively and at the final follow-up (>5 years). Surgery-related complications were also recorded. Results: The studied population's mean age was 69.4 years, while most of them were females (397; 65.8%). The mean follow-up was 6.9 years. The median HHS at the 1-month follow-up was 74, compared to the 47 preoperatively (p-value < 0.0001). At the final follow-up, median HHS was 94. At the 1-month follow-up, mean adduction was 19.9° (compared to 15.4° preoperatively; p < 0.0001), mean abduction 24.3° (18.2° preoperatively; p < 0.0001), mean flexion 107.8° (79.1° preoperatively; p < 0.0001), mean external rotation 20.1° (12.1° preoperatively; p < 0.0001) and mean internal rotation 15.3° (7.2° preoperatively; p < 0.0001). ROM further improved until the final follow-up; mean adduction reached 22°, mean abduction 27.1°, mean flexion 119.8°, mean external rotation 24.4° and mean internal rotation 19.7°. Regarding complications, 1.3% of the sample suffered anterior traumatic dislocation, in 1.8% an intraoperative femoral fracture occurred, while 1.2% suffered periprosthetic joint infection. Conclusions: The modified ALMIS technique exhibited excellent clinical outcomes at short-, mid- and long-term follow-up, by significantly improving hip ROM and the HHS. Careful utilization of this technique, after adequate training, should yield favorable outcomes, while minimal major complications should be expected.

Results after spica cast immobilization following hip reconstruction in 95 cases: is there a need for alternative techniques?

INTRODUCTION: Developmental dysplasia of the hip (DDH), neurogenic dysplasia of the hip (NDH), and Perthes disease often require surgical treatment. Spica casting is a common postoperative immobilization. The purpose of this study was to evaluate the complications related to the immobilization. MATERIALS AND METHODS: In a retrospective analysis, we included 83 patients (95 hips), who underwent hip reconstructive surgery between 2008 and 2018. We had 43 female and 40 male patients. Age reached from 3 months to 19 years. All patients were treated with a spica cast postoperatively for a 6-week protocol. Complications were analyzed using the full medical documentation and classified according to Clavien-Dindo. RESULTS: We had complications in 23 patients (27.7%). We counted superficial skin lesions in seven, deep skin lesions in three, spasticity of adductors in three, subluxation in two, infection of the plate in one, fracture of the plate in one, compliance problem in one, dislocations of the cast in two, reluxation in one, delayed bone healing in one and spasticity of knee flexors in one case. According to the classification of Clavien-Dindo, we were able to count ten type I, four type II, nine type III, zero type IV and zero type V adverse events. CONCLUSION: The usage of a spica cast after hip reconstructive surgery is still the most popular way of aftertreatment. It has a low complication rate, which may be lowered by well-applied casts and foam padding. Known complications such as spasticity in patients with cerebral palsy, skin lesions, and pressure sores should be observed and avoided. Shorter protocols for immobilization with the usage of foam padding and foam splints lead to less complications. CLINICAL RELEVANCE: Evidence level level IV, case series.

Hip reconstruction in closed triradiate cartilage: long-term outcomes in patients with cerebral palsy.

INTRODUCTION: Hip reconstruction is an established procedure in pediatric patients with neurogenic hip dislocation. An open triradiate cartilage provides the advantage of a high plasticity of the bone which prevents an intraarticular fracture and postoperative adaptation of shape. Some patients with dislocated hips, however, arrive late. A hip reconstruction is still feasible as shown earlier but the long-term risk for osteoarthritis, and recurrence of dislocation, and functional outcome is unknown. It is the aim of our investigation to evaluate long-term clinical and radiological outcomes of hip reconstruction by Dega type pelvic osteotomy performed after fusion of the triradiate epiphyseal cartilage in patients suffering from cerebral palsy. MATERIAL AND METHODS: We retrospectively analyzed 43 hips in 37 patients with a hip reconstruction for correction of hip dislocation or subluxation. In all patients, the triradiate cartilage was fused before surgery. Age at surgery was 15 years and 2 months on average and follow-up time was mean 13 years 5 months. RESULTS: Mean Kellgren Lawrence score at final follow-up was significantly higher than at preoperative investigation (P < 0.00001). At long-term follow-up 3 of 43 hips had developed pain, and 1 of them required arthroplasty. Reimers´ migration index was stable over the years and was not higher at last follow-up compared to the index observed shortly after surgery (P = 0.857), so was the Sharp angle (P = 0.962). We found no significant reduction in the range of motion of the hip in the sagittal plane. CONCLUSION: We noted mild radiological signs of osteoarthritis which possibly occur due to an intraarticular acetabulum fracture during bending down the acetabulum. Nevertheless, hip reconstruction in patients with cerebral palsy and closed triradiate cartilage remains a valuable option as it results in a stable, painless hip for more than a decade.

Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy.

The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. Given its infrequency, there is scarcity of literature describing appropriate surgical management and operative technique for addressing this instability. This study reports a case of gross hip instability following hip arthroscopy, describing a novel technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft. Level of evidence V, Case Study.

Hip-joint congruity after Dega osteotomy in patients with cerebral palsy: long-term results.

INTRODUCTION: Neurogenic hip dislocation is quite common in children with cerebral palsy (CP). The purpose of this study was to evaluate the long-term outcome of single-event multilevel surgery (SEMLS) in combination with hip reconstruction by using a periacetabular osteotomy as described by Dega concerning post-operative remodeling and plasticity of the femoral head post-operatively. METHODS: A total of 72 patients with CP as the primary disease and in whom a complex surgical hip reconstruction was performed during SEMLS between 1998 and 2004 were included in the study. There were 45 men and 27 women, with a median age of 7.6 (4.7-16.3) years at the time SEMLS was performed. The mean follow-up time was 7.7 years (4.9-11.8). X-rays were taken before and after surgery, and Rippstein 1 and 2 were used for follow-up. As the most reliable value for decentration, migration percentage (MP) as described by Reimers was used. To measure hip-joint cover at follow-up, the centre-edge angle was used. The hip was divided into four different categories according to sphericity and congruity. Using this approach, we could evaluate joint remodeling. RESULTS: Pre-operatively, the mean MP measured by X-ray was 68 %. Directly after surgery, this value decreased on average by 12 % and at the long-term follow-up was 16.0 % on average. A high rate of incongruence was observed on X-rays taken directly after surgery: 66 hip joints were classified as incongruent. The number of aspherical and incongruent joints decreased to 54 at the follow-up examination. CONCLUSION: Data of our study with high plasticity of the hip joint suggest that even if the femoral head is deformed and a persistent incongruency after surgery is expected, hip reconstruction can be recommended.

Comparisons of preoperative three-dimensional planning and surgical reconstruction in primary cementless total hip arthroplasty.

Reconstruction of important parameters such as femoral offset and torsion is inaccurate, when templating is based on plain x-rays. We evaluate intraoperative reproducibility of pre-operative CT-based 3D-templating in a consecutive series of 50 patients undergoing primary cementless THA through an anterior approach. Pre-operative planning was compared to a postoperative CT scan by image fusion. The implant size was correctly predicted in 100% of the stems, 94% of the cups and 88% of the heads (length). The difference between the planned and the postoperative leg length was 0.3 + 2.3 mm. Values for overall offset, femoral anteversion, cup inclination and anteversion were 1.4 mm ± 3.1, 0.6° ± 3.3°, -0.4° ± 5° and 6.9° ± 11.4°, respectively. This planning allows accurate implant size prediction. Stem position and cup inclination are accurately reproducible.

Redisplacement rate after bony hip reconstructive surgery in nonambulatory patients with cerebral palsy: a systematic review and meta-analysis.

Purpose: Up to 90% of nonambulatory patients with cerebral palsy (CP) experience hip displacement during their lifetime. Reconstructive surgery is recommended. Redisplacement rate is an outcome parameter. Methods: In a systematic literature review (MEDLINE, Embase and CENTRAL databases) until January 2023 we searched for reports with redisplacement rates after bony hip reconstructive surgery in nonambulatory patients. Quantitative data synthesis, subgroup analysis and meta-regression with moderators were carried out. Results: The pooled mean redisplacement rate was 16% (95% CI: 12-21%) with a prediction interval of 3-51% (Q: 149; df: 32; P < 0.001; I2: 78%; τ2: 0.67 and τ: 0.82) in 28 studies (1540 hips). Varus derotation osteotomy (VDRO) alone showed a higher redisplacement rate than VDRO + pelvic osteotomy (30% vs 12%, P < .0001). Mean age in the VDRO-alone subgroup was 7.1 years and in the combined group 9.5 years (P = .004). In meta-regression, lower redisplacement rates were observed with higher preoperative migration index (MI) (correlation coefficient: -0.0279; P = .0137), where comprehensive surgery was performed. Variance in true effects are explained by type of bone surgery (57%), preoperative MI (11%), age (5%) and MI for definition of failure (20%). No significant reduction in the redisplacement rate could be observed over the mid-years of studies (1977-2015). Conclusion: Our pooled data support the more extensive surgical approach in patients with high preoperative MI and emphasize the superiority of combined surgery. Studies should report a coordinated set of parameters and outcome classifications according to internationally accepted gradings to reduce redisplacement in future.

Press-fit vs threaded acetabulum components for total hip arthroplasty - A systematic review with metanalysis.

Background: Threaded acetabular components (TACs) have been shown to offer greater initial stability compared to press-fit acetabular components (PFACs). Despite these biomechanical advantages, the use of threaded cups remains. This study compares the outcomes of TACs to PFACs in total hip arthroplasty (THA), providing evidence-based data regarding their failure rates and radiological evaluation. Methods: A meticulous research of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted, to identify all articles regarding the outcome of the use of TCAs compared to PFACs in THA. Subsequently, statistical analysis with metanalysis concerning: 1) the instances of revision due to aseptic loosening and 2) the radiological evaluations of TACs compared to PFACs and sensitivity analysis were performed. Results: This metanalysis encompassed seven studies, enrolling 7878 cases of THA utilizing PFAC, and 6684 cases using TAC. The overall odds ratio (OR) for revision due to aseptic loosening in THA using PFAC compared to TAC was 3.10 (95 % CI 0.37-25.72). Additionally, when assessing radiolucency findings across the same categories, the pooled OR was 0.53 (95 % CI 0.26-1.08). An examination of studies with larger sample sizes revealed no statistically significant variance. After adjusting for age, no substantial difference was detected. However, upon gender adjustment, it was observed that females undergoing THA with PFAC had a 5-fold risk of revision (OR = 5.26, 95 % CI 0.25-111.91, p-value = 0.29) compared to females with TAC, although without reaching statistical significance. Moreover, females exhibited a slightly elevated risk for revision due to aseptic loosening post-PFAC THA compared to males [(OR = 5.26, 95 % CI 0.25-111.91) (OR = 2.51, 95 % CI 0.01-1051.68) respectively], and for radiolucency findings [(OR 0.74, 95 % CI 0.20-1.11) (OR 0.29, 95 % CI 0.03-3.36) respectively]. Conclusions: The PFACs remain the main option for total hip reconstruction, while TACs might be a viable alternative, especially in cases of osteoporosis.

Three-dimensional reconstruction of hip and groin region by division and rotation of skin paddle using oblique rectus abdominis musculocutaneous flap after squamous cell carcinoma resection.

Reconstructing extensive defects in the hip and groin region is challenging. Although the technique of wrapping the flaps is often chosen, achieving effective coverage of defects is difficult because of the tissue bulge in the center, and a skin graft is frequently required. We herein report a case of successful hip "corner" reconstruction using a pedicled oblique rectus abdominis musculocutaneous flap with division and rotation of the skin paddles after squamous cell carcinoma resection. The patient had a history of immunosuppressive treatment, radiation therapy, and surgeries on the ipsilateral thigh. Our technique minimized the sacrifice of the flap donor site, achieved primary closure, and resulted in a favorably shaped reconstruction with respect to three-dimensional morphology. The patient's postoperative quality of life was ultimately improved.

Reconstruction with a cage outlives patients with metastatic disease involving the acetabulum.

AIM: The aim of this study was to determine whether patients treated with a caged reconstruction for metastatic acetabular disease would have a construct survival superior to that of their life expectancy. PATIENTS AND METHODS: We undertook a retrospective study, in a single centre in the United Kingdom, reviewing outcomes for 19 patients (20 hips) treated with a cage reconstruction for metastatic disease of their acetabulum over 6 years. Inclusion criteria were those with an impending fracture of the acetabulum, metastatic dissociation, fracture of the acetabulum and or femur and those whose life expectancy was considered by the oncology team to be >6 months. RESULTS: In all patients the Restoration GAP II acetabular cage (Stryker, Howmedica Osteonics Corp, NJ, USA) was used in conjunction with a cemented acetabular cup and cemented femoral stem. The mean age at the time of surgery was 68 (44-87) years with breast cancer being the most common primary malignancy (31%) followed by prostate cancer (26%).Radiological survivorship estimates were 94.1% (95% CI, 99.2-65.0) at 12 and 24 months, 70.6% (95% CI, 93.6-16.0) at 36 months and 35.3% (95% CI, 78.2-1.2) at 48 months. There were 3 radiological failures of the implant due to disease progression. Complications occurred in 3 patients with 2 developing deep infection which was treated with suppressive antibiotic therapy following aspiration of the hip. 1 patient suffered a hip dislocation following trauma which was successfully reduced closed and no further intervention was required. CONCLUSIONS: This study represents the first published case series of the use of the GAP II cage in patients with metastatic acetabular disease. The construct generally outlives the patient and hence is suitable for the treatment of acetabular metastases.

Hip reconstruction in cerebral palsy: Lessons from a single center and 137 hips.

Background: This large, retrospective, single-center study aimed to compare the outcomes of unilateral hip reconstruction and bilateral hip reconstruction in children with non-ambulatory cerebral palsy and ascertain risk factors for recurrent instability and reoperation. Method: We performed a retrospective review of 137 hip reconstructions performed for patients with cerebral palsy. Preoperative and postoperative clinical and radiological parameters were documented, including hip migration percentage, acetabular index, the Gross Motor Function Classification System, the Melbourne Cerebral Palsy Hip Classification System, hip abduction, and pelvic obliquity. Results: Overall, 49 patients underwent bilateral hip reconstruction, and 37 patients underwent unilateral hip reconstruction. In the unilateral hip reconstruction group, the reconstructed hip remained stable (with a migration percentage < 33%) in 59% of patients compared to 74.4% of the more affected hips in the bilateral hip reconstruction group (p = 0.02). Of the unreconstructed hip in the unilateral hip reconstruction group, 74.4% remained stable (with a migration percentage < 33%), compared to 78.8% of the less affected hips in the bilateral hip reconstruction group. A level pelvis was maintained at final follow-up in significantly more patients in the bilateral hip reconstruction group than the unilateral hip reconstruction group (p = 0.002). Further surgical intervention was performed in 41% of the unilateral hip reconstruction group, compared with 11.5% in the bilateral hip reconstruction group (p = 0.001). Surgery performed under the age of 8 years and not performing an acetabular osteotomy were found to be risk factors for recurrent instability in all groups. Conclusion: Our series suggests that in terms of recurrent instability after hip reconstruction in cerebral palsy, protective factors against this complication include bilateral hip reconstruction, hip reconstruction after 8 years of age, and the use of an acetabular osteotomy.

Tranexamic Acid in Hip Reconstructions in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Clinical Trial.

Surgical treatment is indicated for hip dislocation in patients with cerebral palsy (CP), but it requires care due to the state of nutrition and associated clinical comorbidities. The use of resources that minimize blood loss and the need for blood transfusions are essential to avoid complications. Tranexamic acid (TXA) has been highlighted for orthopedic surgeries to control intraoperative bleeding; however, there is a lack of large studies for its use in hip surgeries in patients with CP. This study aims to evaluate the efficacy and safety of tranexamic acid to reduce bleeding in pediatric patients with cerebral palsy undergoing surgical treatment for hip instability. A sample of 31 patients with CP who underwent surgical treatment for hip dislocation (hip adductor stretching, varization osteotomy of the proximal femur and acetabuloplasty using the Dega technique) was randomly divided into groups: control (n = 10) and TXA (n = 21). Preoperative and 24 h hemoglobin concentrations, the length of hospital stay (LHS), and intraoperative bleeding (IB) were analyzed. TXA significantly reduced the IB (p = 0.02). The variance in hemoglobin concentration was lower for the TXA group, but without statistical significance (p = 0.06). There was no difference in LHS. Also, no statistical difference was observed for the number of transfusions (p = 0.08). The findings provide evidence of the effectiveness of TXA in decreasing intraoperative bleeding and its safety for use in pediatric patients with cerebral palsy.

Statistical shape modeling of the large acetabular defect in hip revision surgery.

The assessment of three-dimensional bony defects is important to inform the surgical planning of hip reconstruction. Mirroring of the contralateral side has been previously used to measure the hip center of rotation (CoR). However, the contralateral side may not be useful when diseased or replaced. Statistical Shape Models (SSMs) can aid reconstruction of patient anatomy. Previous studies have been limited to computational models only or small patient cohorts. We used SSM as a tool to help derive landmarks that are often absent in hip joints of patients with large acetabular defects. Our aim was to compare the reconstructed pelvis with patients who have previously undergone hip revision. This retrospective cohort study involved 38 patients with Paprosky type IIIB defects. An SSM was built on 50 healthy pelvises and used to virtually reconstruct the native pelvic morphology for all cases. The outcome measures were the difference in CoR for (1) SSM versus diseased hip, (2) SSM versus plan, and (3) SSM versus contralateral healthy hip. The median differences in CoR were 31.17 mm (interquartile range [IQR]: 43.80-19.87 mm), 8.53 mm (IQR: 12.76-5.74 mm), and 7.84 mm (IQR: 10.13-5.13 mm), respectively. No statistical difference (p > 0.05) was found between the SSM versus plan and the SSM versus contralateral CoRs. Our findings show that the SSM model can be used to reconstruct the absent bony landmarks of patients with significant lysis regardless of the defect severity, hence aiding the surgical planning of hip reconstruction and implant design.

The direct anterior approach for conversion to total hip arthroplasty after acetabular fixation is safe and effective.

INTRODUCTION: Total Hip Arthroplasty (THA) after prior acetabular fracture repair is known to be demanding as studies have shown inferior implant survival rates and higher infection rates for these procedures. The direct anterior (DA) approach might help mitigate some of these risks by utilizing a new surgical tissue plane. However, potential criticisms of the DA approach for these surgeries include the inability to access previous acetabular implants or heterotopic ossification (HO) if they were to inhibit implant placement. The goals of this study are to analyze the efficacy of the DA approach for conversion to hip arthroplasty surgery after previous acetabular fixation. METHODS: After reviewing all records at our institution using current procedural terminology codes, we isolated patients with previous acetabular repair who underwent conversion to THA through the DA approach. Patient records were reviewed, and patients were contacted to obtain Harris Hip Scores. RESULTS: 23 patients (16 males and 7 females) were found with a mean follow-up time of 46 months (range 16-156 months). The mean age was 50 (range 28 - 83) and mean BMI was 28.5 (range 15.2 - 39.2). The average blood loss was 400 ml (range 200 - 900). The average operative time was 140 min (range 85-200 min). In 7 cases (32%) implants were encountered during acetabular reaming but the implants were either removed entirely or removed partially with a burr so that the acetabular cup could be positioned within acceptable parameters. In 2 cases pre-operative HO was encountered and was resected. The average Harris Hip Score at final follow-up was 92 (range 75 - 100). There were no deep infections and no neurovascular injuries encountered. 2 patients (9%) underwent revision surgery for aseptic femoral stem loosening. There was 1 anterior dislocation (4.5%) at 3 days post-operatively that was successfully treated with closed reduction and maintenance of hip precautions. Otherwise, the remaining 19 (86%) patients went on to uncomplicated recovery. CONCLUSION: This is the largest known cohort analyzing the DA approach for conversion to hip arthroplasty after previous acetabular fixation. Overall, we demonstrate that the DAA is safe for conversion THA after acetabular fixation.

Race and Sex Disparities in Lower Extremity Total Joint Arthroplasty: A Retrospective Database Study.

INTRODUCTION: Total joint arthroplasty (TJA) is successful in improving health-related quality of life. However, outcomes vary in the literature due to modifiable and non-modifiable factors. Modifiable factors consist of body mass index (BMI), nutrition, and tobacco use. Non-modifiable risk factors include age, race, sex, and socioeconomic status. Prior literature has focused on racial disparities in terms of the utilization of lower extremity arthroplasty. The purpose of this study is to determine the effect of race and sex on the in-hospital complication rate, length of stay, and charges associated with primary TJA. METHODS: This retrospective cohort utilized complex survey data from the National Inpatient Sample (NIS) between 2016 and 2019. The use of the International Classification of Disease-10 Procedure Codes (ICD-10 PCS) for right hip, left hip, right knee, and left knee TJA yielded a preliminary total of 2,660,280 patients. The exclusion criteria were bilateral arthroplasty and concomitant unilateral hip and knee arthritis. Major complications were defined as acute myocardial infarction, cardiac arrest, pulmonary embolism, adult respiratory distress syndrome, stroke, shock, and septicemia. Odds ratio (OR) and beta coefficients were adjusted for age, sex, primary payer, hospital region, hospital teaching status, and year. Total charges were adjusted for inflation using the Consumer Price Index data reported by the US Bureau of Labor Statistics. RESULTS: A total of 2,589,510 patients met our inclusion criteria; 87.6%, 5.9%, 4.8%, 1.4%, and 0.3% of people were 'White', 'Black', 'Hispanic', 'Asian, or Pacific Islander', and 'Native American', as defined by the National (Nationwide) Inpatient Sample (NIS) Variable 'RACE'. Black individuals experienced a significantly greater major complication rate compared to White individuals (0.87% vs. 0.74%, OR 1.25, p-value = 0.0004). Black and Hispanic individuals experienced a significantly greater minor complication rate compared to White individuals (6.39% vs. 4.12%, odds ratio (OR) 1.61, p-value < 0.0001; 4.68% vs. 4.12%, OR 1.17, p-value < 0.0001). Black, Hispanic, Asian or Pacific Islander, and Native American individuals stayed, on average, 0.33, 0.19, 0.19, and 0.25 days longer than White individuals (2.78, 2.54, 2.55, 2.56 vs. 2.37 days, p<0.0001). None of these statistically significant differences exceeded the established minimal clinically important difference of two days. Black, Hispanic, and Asian or Pacific Islander patients were charged $5,751, $18,656, and $12,119 more than White patients ($72,122, $85,027, $78,490, and $59,297 vs. $66,371, p ≤ 0.0165). Native American patients were charged $7,074 less than White patients ($59,297 vs. $66,371, p < 0.0001). CONCLUSIONS: Black and Hispanic TJA patients may have higher complication rates than White TJA patients. The differences in length of stay between race groups may not affect outcomes. Hispanic patients received significantly more charges than White patients, and Native American patients received significantly fewer charges than White patients after controlling for non-modifiable risk factors. Addressing the charge disparities may reduce the total national cost burden associated with TJA. The present study highlights the need for further studies on healthcare outcomes related to race and sex.

Hip Surveillance and Management of Hip Displacement in Children with Cerebral Palsy: Clinical and Ethical Dilemmas.

Hip displacement is the second most common musculoskeletal deformity in children with cerebral palsy. Hip surveillance programs have been implemented in many countries to detect hip displacement early when it is usually asymptomatic. The aim of hip surveillance is to monitor hip development to offer management options to slow or reverse hip displacement, and to provide the best opportunity for good hip health at skeletal maturity. The long-term goal is to avoid the sequelae of late hip dislocation which may include pain, fixed deformity, loss of function and impaired quality of life. The focus of this review is on areas of disagreement, areas where evidence is lacking, ethical dilemmas and areas for future research. There is already broad agreement on how to conduct hip surveillance, using a combination of standardised physical examination measures and radiographic examination of the hips. The frequency is dictated by the risk of hip displacement according to the child's ambulatory status. Management of both early and late hip displacement is more controversial and the evidence base in key areas is relatively weak. In this review, we summarise the recent literature on hip surveillance and highlight the management dilemmas and controversies. Better understanding of the causes of hip displacement may lead to interventions which target the pathophysiology of hip displacement and the pathological anatomy of the hip in children with cerebral palsy. We have identified the need for more effective and integrated management from early childhood to skeletal maturity. Areas for future research are highlighted and a range of ethical and management dilemmas are discussed.

The variability of CT scan protocols for total hip arthroplasty: a call for harmonisation.

CT is the principal imaging modality used for the pre-operative 3D planning and assessment of total hip arthroplasty (THA). The image quality offered by CT has a radiation penalty to the patient. Higher than necessary radiation exposure is of particular concern when imaging young patients and women of childbearing age, due to the greater risk of radiation-induced cancer in this group. A harmonised low-dose CT protocol is needed, evidenced by the huge variability in the 17 protocols reviewed. The majority of the protocols were incomplete, leading to uncertainty among radiographers when performing the scans. Only three protocols (20%) were optimised for both 'field of view' and image acquisition parameters. 10 protocols (60%) were optimised for 'field of view' only. These protocols included imaging of the relevant landmarks in the bony pelvis in addition to the knees - the reference for femoral anteversion. CT parameters, including the scanner kilovoltage (kV), milliamperage-time product (mAs) and slice thickness, must be optimised with a 'field of view' that includes the relevant bony landmarks. The recommended kV and mAs values were very wide ranging from 100 to 150 and from 100 to 250, respectively. The large variability that exists amongst the CT protocols illustrates the need for a more consistent low-dose CT protocol for the planning of THA. This must provide an optimal balance between image quality and radiation dose to the patient. Current CT scanners do not allow for measurements of functional pelvic orientation and additional upright imaging modalities are needed to augment them.

Custom-Made Articulating Spacer (CUMARS): The Resolution of Periosteal Reaction and Femur Remodelling in Periprosthetic Hip Infection.

Periprosthetic joint infection (PJI) is one of the most common complications after total hip arthroplasty (THA). Two-stage revision surgery is one of the treatment options for PJI, however, it has been associated with poor patient tolerance, reduced patient mobility, and periarticular tissue contracture leading to difficulty during second-stage reconstruction. The custom-made articulating spacer (CUMARS) was developed to provide an alternative that is better tolerated and to reduce the complexity of second-stage reconstruction. This study details the treatment of a patient with PJI post-THA with significant periosteal reaction using a CUMARS construct, which enabled immediate post-operative weight bearing, eventual eradication of infection, restoration of femoral bone stock, and avoidance of second-stage reconstruction.

Telescoping Allograft Prosthetic Composite (APC) Reconstruction of the Femur Following Revision Arthroplasty for Neglected Developmental Dysplasia of the Hip (DDH).

Although uncommon, neglected developmental dysplasia of the hip (DDH) poses a technically demanding problem for treating surgeons. Due to the congenital malformation of the native hip joint and distortion of the surrounding soft tissue, addressing limb-length discrepancy is intricate. Despite detailed planning and meticulous soft tissue handling, complications can be difficult to avoid in these patients even under experienced hands. In this case report, we present a 73-year-old lady with neglected DDH who had undergone initial total hip arthroplasty and subsequent revision surgery that failed due to aseptic loosening. Due to limited length in the distal femur, we used a telescoping allograft prosthetic composite (APC) to provide adequate length to the native distal femur during revision with proximal femur fixation. This technique can help avoid the need for total femur replacement (TFR) surgery, which is more invasive and may require tibia replacement.