Search Results (12)

Life expectancy and overall function of amputated patients have improved significantly over the last few decades; for this reason, amputees are more exposed to primary or secondary degenerative disease of the hip, requiring total hip arthroplasty (THA) surgery. However, during training, not all the surgeons acquire adequate skills to manage these patients, and only a few studies and case reports describe technical pearls and outcomes of THA in patients with ipsilateral lower limb amputation, either above or below the knee. The objective of this narrative review is to present current evidence and surgical tips for performing THA in ipsilateral amputated patients, with a focus on the differences between patients with above- (AKA) and below-knee amputation (BKA). We reviewed manuscripts in major scientific databases, cross-referencing to retrieve adjunctive manuscripts, and summarized all relevant cases. We found 17 manuscripts, spanning 70 years of literature, collecting a total of 39 patients who underwent THA on an ipsilateral amputated limb: 13 AKA, 23 BKA, and 3 through-knee-amputation (TKA). The cohort primarily consists of patients with post-traumatic hip arthritis, often associated with sequelae such as fractures to other bones, soft tissue compromise and heterotopic calcifications. Managing with amputated patients requires careful planning, which includes the study of the residual bone, muscle anatomy, and the level of femoral amputation, as these factors present significant surgical challenges, especially in patients without a knee joint. In dealing with the post-traumatic and multi-comorbidity patients, rehabilitation goals should be considered prior to surgery and should drive the surgical strategy. We found that BKA patients typically have high functional demands, necessitating precise positioning of the components and an aggressive post-operative physiotherapy regimen to avoid unsatisfactory outcomes. AKA patients, on the other hand, often present with altered anatomy, and typically require more surgical instruments and expertise to achieve intraoperative dislocation of the hip joint. Full article

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. Full article

(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. Full article

Background: In patients affected by chronic slipped capital femoral epiphysis (C-SCFE), the performance of a subcapital osteotomy is an effective procedure to correct the deformity at the proximal femur. However, the rate of postoperative complications is very high, with iatrogenic avascular necrosis of the femoral head (AVN) being the most bothersome. To overcome the risk of AVN, the modified Dunn procedure according to Ganz and, more recently, the Vascular Sparing Subcapital Osteotomy (VASSCO) technique have been proposed; however, only short-term follow-up studies are available on the latter technique being used. The aim of this study is therefore to show our mid-term clinical and radiological results with the VASSCO technique. Materials and Methods: A total of 26 patients underwent VASSCO for moderate or severe stable C-SCFE between 2012 and April 2016 with an average 10-year follow-up (range 8–12 years). The outcomes was evaluated using the HHS and pre- and postoperative ROM. The radiological outcomes and complications were collected. Results: No major intraoperative complications occurred; three patients reported postoperative transient apraxia of the lateral femoral cutaneous nerve, which completely recovered in six months. All the radiological outcomes showed substantial improvement postoperatively. One case patient developed AVN of the femoral head and required a total hip arthroplasty after 12 years. Conclusions: The current data suggest that VASSCO osteotomy is a reliable technique with very good clinical results at mid-term follow-up; it could be considered a valuable alternative to using more complex techniques to restore the proximal femoral anatomy in moderate to severe C-SCFE. Full article

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. Full article

(1) Background: Periprosthetic joint infections (PJIs) represent a small yet important risk when undertaking a joint arthroplasty; they occur in approximately 1–2% of treatments. These infections create a medical and financial burden for patients and healthcare systems. Despite the introduction of recognized best clinical practices during arthroplasty operations, it is not yet possible to further reduce the risk of infection after surgery. The purpose of this review is to raise awareness of the potential role of gut dysbiosis in the development of PJIs and to highlight the potential of the gut bacteriome as a possible target for preventing them. (2) Methods: We compiled all the available data from five databases, examining the effects of gut dysbiosis in human and murine studies, following PRISMA guidelines, for a total of five reviewed studies. (3) Results: One human and one murine study found the Trojan horse theory applicable. Additionally, inflammatory bowel diseases, gut permeability, and oral antibiotic ingestion all appeared to play a role in promoting gut dysbiosis to cause PJIs, according to the other three studies. (4) Conclusions: Gut dysbiosis is linked to an increased risk of PJI. Full article

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. Full article

Background and objectives: Total hip arthroplasty (THA) in obese patients (BMI > 30) is considered technically demanding, and it is associated with higher rates of general and specific complications including infections, component malpositioning, dislocation, and periprosthetic fractures. Classically, the Direct Anterior Approach (DAA) has been considered less suitable for performing THA surgery in the obese patient, but recent evidence produced by high-volume DAA THA surgeons suggests that DAA is suitable and effective in obese patients. At the authors’ institution, DAA is currently the preferred approach for primary and revision THA surgery, accounting for over 90% of hip surgeries without specific patient selection. Therefore, the aim of the current study is to evaluate any difference in early clinical outcomes, perioperative complications, and implant positioning after primary THAs performed via DAA in patients who were divided according to BMI. Material and methods: This study is a retrospective review of 293 THA implants in 277 patients that were performed via DAA from 1 January 2016 to 20 May 2020. Patients were further divided according to BMI: 96 patients were normal weight (NW), 115 were overweight (OW), and 82 were obese (OB). All the procedures were performed by three expert surgeons. The mean follow-up was 6 months. Patients’ data, American Society of Anesthesiologists (ASA) score, surgical time, days in rehab unit, pain at the second post-operative day recorded by using a Numerical Rating Scale (NRS), and number of blood transfusions were recorded from clinical charts and compared. Radiological evaluation of cup inclination and stem alignment was conducted on post-operative radiographs; intra- and post-operative complications at latest follow-up were recorded. Results: The average age at surgery of OB patients was significantly lower compared to NW and OW patients. The ASA score was significantly higher in OB patients compared to NW patients. Surgical time was slightly but significantly higher in OB patients (85 ± 21 min) compared to NW (79 ± 20 min, p = 0.05) and OW patients (79 ± 20 min, p = 0.029). Rehab unit discharge occurred significantly later for OB patients, averaging 8 ± 2 days compared to NW patients (7 ± 2 days, p = 0.012) and OW patients (7 ± 2 days; p = 0.032). No differences in the rate of early infections, number of blood transfusions, NRS pain at the second post-operative day, and day of post-operative stair climbing were found among the three groups. Acetabular cup inclination and stem alignment were similar among the three groups. The perioperative complication rate was 2.3%; that is, perioperative complication occurred in 7 out of 293 patients, with a significantly higher incidence of surgical revisions required in obese patients compared to the others. In fact, OB patients showed a higher revision rate (4.87%) compared to other groups, with 1.04% for NW and 0% for OW (p = 0.028, Chi-square test). Causes for revision in obese patients were aseptic loosening (2), dislocation (1), and clinically significant post-operative leg length discrepancy (1), with a revision rate of 4/82 (4.87%) during follow-up. Conclusions: THA performed via DAA in obese patients could be a solid choice of treatment, given the relatively low rate of complications and the satisfying clinical outcomes. However, surgical expertise on DAA and adequate instrumentation for this approach are required to optimise the outcomes. Full article

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. Full article

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. Full article

Introduction: The pathologic anatomy of Crowe III is characterized by the erosion of the superior rim of acetabulum, with a typical bone defect in its supero–lateral portion. The performance of a total hip arthroplasty requires the management of the acetabular bone defect, and femoral head autograft can be a valid option to optimize implant coverage. Material and Methods: In all, eight Crowe III patients (nine hips), seven of which having unilateral hip affected, and one with bilateral involvement by secondary osteoarthritis in DDH; maximum limb length discrepancy (LLD) of 3.5 cm in unilateral patients. All were operated on by direct anterior approach. Patients were evaluated in terms of clinical, surgical, and radiological (center-edge, horizontal coverage, cup inclination) parameters. Results: Cup placement was implanted with a mean of 39.5 ± 7.5°. Stem alignment showed average 1.5 ± 2.3° in valgus. LLD showed an overall average preoperative of −29.5 ± 10.5 mm at the affected side, with a significant improvement to −2.5 ± 6.4 mm (p = 0.023). The mean initial coverage evaluated like a percentage of the horizontal bone host was 52.1 ± 7.1%, while the mean final coverage at the last post-operative X-ray from femoral autograft bone was 97.0 ± 4.5% with an average improvement of 44.5%. Average CE improved from −9.5 ± 5.2° (CE I) to the immediate post-operative (CE II) of 40.6 ± 8.2°. At the final follow up, CE III showed a mean of 38.6 ± 6.2°, with an average decrease of 2.0°. Discussion: Acetabular bone defect in Crowe III DDH patients undergoing THA by DAA, can be efficiently managed by massive autograft femoral head, which allowed an adequate and long-lasting coverage of the implant, with cup positioning at the native acetabulum. Full article

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. Full article