Dario Regis

Although total hip arthroplasty (THA) is a very successful orthopedic operation with high long-term survival rates, some failures may occur and considerably influence the final outcome. Early dislocation following primary THA is a rare but challenging complication, which may affect functional recovery and patient satisfaction, especially in case of recurrence. Moreover, it is one of the most common reasons for revision, and is associated with substantial social, health, and economic costs. The aim is to critically review the current evidence on the management of early dislocation after primary THA, with particular focus on post-reduction treatment strategies and the role of immobilization techniques. Particular attention was given to the evidence base supporting various clinical approaches. The review highlights a lack of consensus regarding optimal post-reduction management. Several methods have been proposed, but most are supported by limited data and small case series. Comparative studies are scarce, and clinical outcomes are inconsistent. Based on current findings, the recommended post-reduction management practice remains controversial, but the effectiveness of immobilization in preventing recurrence is not supported by clinical evidence, and therefore should be avoided. Further high-quality studies are needed to establish standardized, evidence-based protocols that can improve patient outcomes and reduce the risk of recurrence.

Due to the increasing ageing population, femoral neck fracture (FNF) is a common and significant public health issue in the elderly, as it significantly impacts patients’ quality of life, frequently leading to severe disability. Undoubtedly, hip replacement is the standard current of care for displaced FNF in this population, as it can provide pain relief and allow immediate return to mobility. However, hip arthroplasty may present severe specific complications, such as implant dislocation and infection, which may increase mortality and morbidity, especially in more frail patients. Therefore, in this particular population, alternative treatments should be considered. Girdlestone resection arthroplasty, which includes excision of the femoral head, is a salvage procedure which was first described for the management of chronic tuberculous coxitis, and then widely used in uncontrolled infected hip replacements. This article provides an updated outcome analysis of hip resection arthroplasty as a primary definitive treatment for FNF in frail non-ambulatory patients.

Total hip arthroplasty (THA) is one of the most successful elective operations in orthopedic surgery for improving pain and functional disability in patients with end-stage joint disease. However, dislocation continues to be a troublesome complication after THA, as it is a leading cause of revision and is associated with substantial social, health, and economic costs. It is a relatively rare, usually early occurrence that depends on both the patients’ characteristics and the surgical aspects. The most recent and important finding is the special attention to be given preoperatively to spinopelvic mobility, which is closely related to the incidence of dislocation. Consequently, clinical and radiographic assessment of the lumbar spine is mandatory to identify an altered pelvic tilt that could suggest a different positioning of the cup. Lumbar spinal fusion is currently considered a risk factor for dislocation and revision regardless of whether it is performed prior to or after THA. Surgical options for its treatment and prevention include the use of prostheses with large diameter of femoral head size, dual mobility constructs, constrained liners, and modular neck stems.

Displaced femoral neck fracture (FNF) is a common and significant health issue especially in older population because of the high rates of mortality and complications. The standard surgical treatment is total or partial hip replacement, including a cemented or uncemented stem. The cemented prosthesis is considered the safer option because of a lower rate of periprosthetic fractures (PPFs) as well as an actually reduced risk of bone cement implantation syndrome (BCIS). This retrospective study aims to assess the efficacy and safety of cemented versus uncemented femoral stem for FNF in patients ≥70 years. 139 patients affected by displaced FNF underwent hip replacement, receiving 89 cemented (64%) and 50 uncemented (36%) stems. Inclusion criteria were: ≥70 years of age, an ICD-9-CM diagnose code 820.00, 820.01, 820.02, 820.03, 820.10, 820.8, and a minimum 1-year follow-up. A p value <0.05 was considered statistically significant. Surgical time, overall perioperative complication rate with a particular focus on the thromboembolic events, and PPFs incidence were evaluated comparing cemented and uncemented group. No difference in duration of surgery was found. Intraoperative complications were not detected. Pulmonary embolism and deep vein thrombosis were observed each in 1 case of cemented prosthesis. Periprosthetic femoral fractures occurred only in the uncemented group postoperatively, with a statistically significant difference (p<0.05). The low incidence of BCIS and the higher risk of postoperative PPFs in cemented and uncemented stems, respectively, suggest that the use of cementation is a safer procedure.

Purpose The aim of this retrospective study was to evaluate the medium-term clinical and radiographic results of current generation metal-on-metal resurfacing prostheses performed through anterolateral approach. Materials and methods Fifty-seven hips in 52 patients underwent resurfacing arthroplasty. Two patients died from unrelated causes, leaving 55 hips in 35 males (3 bilateral) and 15 females (2 bilateral), with a mean age at surgery of 56.2 years (range, 27–70 years). Clinical and radiographic assessment was carried out preoperatively and at follow-up in all the survived cases. The cumulative survival rate was determined according to the method of Kaplan–Meier. Results At a mean follow-up of 5.2 years (range, 1.8–9.1 years), 2 HRs of the same female patient were revised because of early loosening of the acetabular component. Deep venous thrombosis and transient femoral nerve palsy occurred both in 1 case. No specific complications of HR were observed. Average Harris hip score improved significantly from 59.8 points (range, 30.4–90.6) preoperatively to 93.7 points (range, 53–100) at the latest examination. Neck narrowing showed an average of 3.27%, but it never exceeded 10%. Nonprogressive acetabular radiolucencies and osteolysis were detected both in 2 hips. A high rate of patients (32, 60.4%) developed heterotopic ossifications, although low-grade in most cases (27, 84.4%). The cumulative survival rate at 9.1 years with revision for any reason as the end point was 93.0%. Conclusions The early clinical and radiographic results of modern metal-on-metal hip resurfacing performed through an anterolateral approach are promising, but longer-term follow-up studies are necessary.

Patellar tendon rupture after anterior cruciate ligament (ACL) reconstruction is a rare complication which usually occurs in the early postoperative period during rehabilitation. The management of open avulsions from tibial tuberosity has not been clearly defined yet. We describe a previously unreported case of traumatic and open patellar tendon avulsion from tibial tuberosity one year following ACL reconstruction in an elite football player which was successfully treated with suture anchors.

Surface replacement arthroplasty (SRA) is an alternative to stemmed total hip arthroplasty (THA) providing a femoral bone preserving procedure. Because of the wider surgical dissection, an increased blood loss could be expected. This retrospective study evaluates the transfusion requirement in two homogeneous groups of patients who underwent primary hip replacement electively. Perioperative haematological data of 42 hip resurfacing procedures and 41 conventional cementless THAs were compared. The pre- and post-operative haemoglobin (Hb) levels and the amount of blood transfusions were registered. The median values were compared with use of the non-parametric Wilcoxon signedrank test. In the SRA group, a significantly increased (p<0.02) preoperative Hb concentration (13.1 g/dL, range 10.9 to 15.6) was detected in comparison with the THA group (12.5 g/dL, range 10.4 to 15.2). In the resurfacing procedures a median of 900 mL (range 600 to 1500) were transfused vs. 600 (range 300 to 1500) in the conventional THAs, demonstrating a significantly higher transfusion requirement (p<0.04). Whereas hip resurfacing is a femoral bone preserving alternative to conventional THA with comparable clinical and radiographic outcomes, higher blood loss and transfusion requirement may occur.

Pelvic osteolysis induced by particulate debris derived from bearing surfaces is a well-known complication following total hip arthroplasty (THA). Atraumatic fractures of the greater trochanter (GT) associated with osteolytic lesions have been occasionally described. We present a case of a 71-year-old male patient who sustained an undisplaced fracture of the GT nine years following cementless metal-on-polyethylene THA. The fracture occurred through a 2.5-cm large osteolytic area, and no hip trauma was recorded. Conventional radiographs revealed peculiar signs of massive wear of the polyethylene acetabular liner (marked eccentricity of the prosthetic head and extensive osteolysis around the iliac screws), allowing to immediately conclude about the benign nature of the pathological fracture. To our knowledge, a two-stage management, planning conservative healing of the fracture and subsequent surgical replacement of the worn acetabular liner, has never been previously detailed.