Search Results (56)

Objectives: The association between osteonecrosis (ON) and Coronavirus Disease of 2019 (COVID-19) was reported early during the pandemic. ON of the femoral head (ONFH) is particularly problematic, as it may destroy the joint and lead to arthroplasty, although early diagnosis and treatment might mitigate its progression. The aim of the present study was to quantify the prevalence of symptomatic and asymptomatic ONFH in patients with severe COVID-19 treated with high doses of corticosteroids during the first pandemic wave. Methods: For this prospective, observational, monocentric cohort study, patients were selected according to the risk factors described for severe acute respiratory syndrome coronavirus in 2002–2004 (SARS-1): young males (<61 years old), high cumulative cortisone doses (≥2 g), severe disease, and followed up clinically and with magnetic resonance imaging. ONFH was classified with the ARCO classification. Results: Out of 1944 patients admitted for COVID-19 from 23 February to 21 May 2020, 856 of 1944 were treated in ICU; 30/1944 were selected according to the inclusion criteria and 27 of 30 were enrolled. The mean age at admission was 54 years (range, 42–60). The mean dose of cumulative cortisone was 6.25 g (range, 2–16). A total of 4/27 (15%) patients had ONFH; only 2 of 4 (50%) were symptomatic, including 1 with multiple ON of major joints. Conclusions: A high-risk cohort of patients with COVID-19 and high doses of corticosteroids had a 15% rate of ONFH, and 2 years after the event, 50% of them were asymptomatic. For those patients, relying solely on clinical evaluation would risk underestimating ONFH, potentially influencing treatment and outcomes. Moreover, other joints might develop ON. The data collected in the present study can be considered for the management of long-COVID. The association between severe COVID-19, high doses of corticosteroids and ONFH suggests the need for focused clinical and magnetic resonance imaging, considering the high rate of asymptomatic patients. Full article

Background: Osteonecrosis of the femoral head is a progressive disorder leading to femoral head collapse and early disability, often affecting young adults. Core decompression (CD) is the most established hip-preserving treatment for early-stage disease, yet the comparative benefits of biological and structural augmentation remain uncertain. Methods: This systematic review and meta-analysis, registered in PROSPERO (CRD420251108396), evaluated 14 studies encompassing 1210 patients treated with CD alone or CD combined with biological (e.g., platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate) or structural (e.g., bone grafting, fibular support) augmentation. Results: Pooled random-effects models demonstrated that biological augmentation yielded significant improvements in Harris Hip Score and pain reduction (VAS) up to 24 months, with early peaks and subsequent stabilization, whereas structural augmentation showed no functional advantage at any time point. Radiological progression and conversion to total hip arthroplasty were not significantly reduced, though long-term trends favored biologically augmented CD. Conclusions: Overall, biological augmentation provides durable functional and symptomatic benefits in early-stage osteonecrosis, supporting its use as a first-line adjunct to CD, while structural augmentation appears less consistent and warrants further evaluation through large, standardized trials. Full article

The management of severely comminuted acetabular posterior wall fractures in young, active patients presents a significant surgical challenge. When anatomical open reduction and internal fixation (ORIF) is not feasible, primary total hip arthroplasty (THA) is often considered but is a suboptimal solution due to concerns over long-term implant survivorship and the inevitability of revision surgery. This single-patient technical note presents a novel joint-preserving technique for managing unreconstructible acetabular posterior wall fractures using with cement-augmented screw fixation via the Kocher–Langenbeck approach. A 28-year-old male sustained a left posterior hip dislocation with a comminuted acetabular posterior wall fracture involving >30% of the articular surface, alongside a tibial shaft fracture, following a high-energy motorcycle collision. Intraoperative assessment confirmed the posterior wall was unreconstructible, with six non-viable osteochondral fragments. A joint-preserving salvage procedure was performed. After debridement, a stable metallic framework was created using three screws anchored in the posterior column. Polymethylmethacrylate (PMMA) bone cement was then applied over this framework in its doughy phase, meticulously contoured to reconstruct the articular surface. The hip was reduced, and the tibia was fixed with an intramedullary nail. The patient was mobilized with weight-bearing as tolerated on postoperative day 3. At the 21-month follow-up, the patient reported no pain during daily activities and only mild discomfort during deep squatting. Radiographic and CT evaluations demonstrated a stable hip joint, concentric reduction, well-maintained joint space, and no evidence of implant loosening or osteolysis. Level of Evidence: V (Technical Note/single-patient Case report). For unreconstructible, comminuted fractures of the non-weight-bearing portion of the acetabular posterior wall in young patients, cement-augmented screw fixation offers a viable joint-preserving alternative to primary THA. This technique provides immediate stability, facilitates early mobilization, and preserves bone stock. While long-term outcomes require further study, this case demonstrates excellent functional and radiographic results at 21 months, presenting a promising new option for managing these complex injuries. Full article

Background/Objectives: The sequelae from conditions affecting the proximal femur may cause instability, pain, leg length discrepancies and abnormal gait. Treatment options include arthrodesis and total hip arthroplasty, but both alternatives have limitations in young patients with severe deformities. Pelvic support osteotomy constitutes a viable option in these cases. The present study analyses the effectiveness and safety of the procedure. Methods: This was a retrospective observational study on patients with an unstable or stiff hip treated with a pelvic support osteotomy. Both the results obtained and the complications that occurred were subjected to a statistical analysis. In addition, a narrative literature review was carried out to elucidate the biomechanical rationale and the results of the technique. Results: This study included a total of 12 patients (8 male and 4 female) with a mean age of 13 years (range: 0–19). All cases were unilateral and the mean follow-up time was 6.9 years (range: 1–10). Preoperative leg length discrepancy was 8 cm (range: 5–10), and all patients presented with a marked Trendelenburg sign. The mean leg lengthening achieved was 8 cm (range: 8–10), following a mean external fixation time of 263 days (range: 180–360), which entails an external fixation index of 32.5 days per centimeter lengthened (range: 25–37). Mean leg length discrepancy fell to 0.9 cm (range: 0–3) and the Trendelenburg sign improved following treatment: it disappeared in three patients (25%), it became mild in seven (58%), and it improved to moderate in two (17%). Eight patients (66%) experienced some sort of complication over the course of treatment. Conclusions: Pelvic support osteotomies, combined with femoral lengthening, are a safe and effective option for managing severely damaged hips in children and adolescents. Full article

In total joint replacement, early aseptic loosening of implants caused by inadequate initial fixation and late aseptic loosening due to stress shielding-related periprosthetic bone remodeling are the main causes of failure. Over the last two decades, additive manufacturing has been revolutionizing the design of cementless orthopaedic implants by enabling biomimetic, highly porous titanium structures that enhance bone ingrowth and osseointegration while reducing stress shielding. The synergy between optimized selective laser-melted highly porous titanium bearing components, ceramic-coated titanium articular surfaces, and vitamin E-stabilized polyethylene liners delivers several benefits essential for implant longevity: reliable initial fixation, improved biological fixation, reduced bone resorption caused by stress shielding, and lower osteolytic reactivity. These benefits have encouraged the synergetic use of these technologies in joint replacement in novel clinical applications. In recent years, novel off-the-shelf, 3D-printed, highly porous titanium implants have been introduced into hip and knee arthroplasty. These newly introduced implants appear to offer an innovative and promising solution, and are particularly indicated for young active patients, elderly patients with osteoporotic bones, and in complex cases. Future clinical research should confirm these novel implants’ superior results in comparison to the current state of the art in cementless joint replacement. The possibility of extending these technologies in the future to other clinical applications such as partial knee prosthesis is discussed. Full article

Background: Ankle osteoarthritis (OA) in hemophiliac patients is an important cause of morbidity. The management of such cases presents unique challenges due to coagulopathy management and surgery technique, especially when it is bilateral. While arthrodesis has traditionally been the procedure of choice for advanced ankle OA, total ankle arthroplasty (TAA) has become an increasingly valuable option due to its potential to restore mobility and function. There is still limited information in the literature regarding the management of these cases, and many questions remain, such as whether to perform surgery in a single stage or two, whether to use anticoagulants or not, and whether to use a tourniquet or not, in addition to the extra precautions required for hemophiliac patients. Methods: This work consists of a case report and a narrative literature review. Results/Case Report: In this article, we present a surgical case involving a young hemophiliac patient with advanced bilateral ankle osteoarthritis who underwent total ankle arthroplasty in a single procedure. In addition to detailing the surgery, we provide several insights that may assist during the intraoperative and postoperative phases, and we compare our approach with the existing literature. Conclusions: With advances in materials and surgical techniques, total ankle arthroplasty has become a viable option, provided that all necessary precautions are meticulously observed. These precautions encompass not only the management of the underlying condition but also careful attention to preoperative, intraoperative, and postoperative care. Further studies with longer follow-up and the use of newer-generation prostheses are still needed. Full article

Background and clinical significance: Osteonecrosis of the femoral head (ONFH) is a disease of the epiphysis caused by the death of osteocytes and osteoblasts, resulting in debilitating pain. ONFH can be traumatic or nontraumatic, with prolonged glucocorticoid use being the leading cause of nontraumatic ONFH. Atopic dermatitis (AD) is a chronic inflammatory skin condition typically treated with topical corticosteroids. ONFH following topical corticosteroid treatment is exceedingly rare, with limited documentation in the literature. We present a case of an under-recognized complication of prolonged topical corticosteroid treatment. Case presentation: We report a case of a 29-year-old Caucasian male patient with sharp right hip pain. Plain radiographs, a CT scan, and an MRI indicated Ficat and Arlet stage 3 ONFH. The patient reported the prolonged uncontrolled use of topical mometasone furoate for five years due to AD. Following the diagnosis, topical corticosteroids were discontinued, and the treatment was shifted to tacrolimus and, subsequently, to oral methotrexate with folic acid. The patient underwent a total hip arthroplasty in June 2022. Given his young age and poor response to previous treatments, he was transitioned to upadacitinib, which led to significant improvement without skin flare-ups or postoperative hip pain. Conclusions: This case highlights the rare, but serious, risk of ONFH associated with long-term topical corticosteroid use. It underscores the importance of monitoring systemic side effects in dermatological therapies and educating patients on proper corticosteroid use. Alternative treatments, such as upadacitinib, should be considered in young male patients to prevent severe complications. Full article

Background: Stress shielding (SS) after total hip arthroplasty (THA) leads to proximal femoral bone loss and increases the risk of complications such as implant loosening and periprosthetic fracture. While various low-stiffness stems have been developed to prevent SS, they often compromise mechanical stability. A novel femoral stem composed of Ti-33.6Nb-4Sn (TNS) alloy offers a gradually decreasing Young’s modulus from proximal to distal regions, potentially improving load distribution and reducing SS. This study aimed to evaluate the mid-term clinical and radiographic outcomes of the TNS stem, with a particular focus on its effectiveness in suppressing SS. Methods: A prospective clinical study was conducted involving 35 patients who underwent THA using the TNS stem, with a minimum follow-up of 7 years. Twenty-one patients with Ti6Al4V metaphyseal-filling stems served as controls. Clinical outcomes were assessed using Japanese Orthopaedic Association (JOA) scores, and radiographic SS was graded using Engh’s classification and analyzed in Gruen zones. Inter-examiner reliability and statistical comparisons between groups were performed using appropriate tests. Results: The TNS group showed significantly higher preoperative JOA scores than the control group, but no significant difference in final scores. Both groups demonstrated significant improvement postoperatively. Third-degree SS occurred in the TNS group, although the overall SS grade distribution was significantly lower than in the control group (p = 0.03). SS frequency was significantly reduced in Gruen Zones 2, 3, and 6 in the TNS group. Conclusions: The TNS stem demonstrated a significant reduction in SS progression compared to conventional titanium stems over a 7-year period, with comparable clinical outcomes. However, the occurrence of third-degree SS indicates that material optimization alone may be insufficient, highlighting the need for further design improvements. Full article

Stress shielding remains a major concern in cementless total hip arthroplasty (THA) due to the stiffness mismatch between femoral stems and surrounding bone. This study investigated the biomechanical and clinical performance of a novel Ti-33.6Nb-4Sn (Ti-Nb-Sn) alloy stem with a graded Young’s modulus achieved through localized heat treatment. A finite element model (FEM) of the Ti-Nb-Sn stem, incorporating experimentally validated Young’s modulus gradients, was constructed and implanted into a patient-specific femoral model. Stress distribution and micromotion were assessed under physiological loading conditions. Clinical validation was performed by evaluating radiographic outcomes at 1 and 3 years postoperatively in 40 patients who underwent THA using the Ti-Nb-Sn stem. FEM analysis showed low micromotion at the proximal press-fit region (4.89 μm rotational and 11.74 μm longitudinal), well below the threshold for osseointegration and loosening. Stress distribution was concentrated in the proximal region, effectively reducing stress shielding distally. Clinical results demonstrated minimal stress shielding, with no cases exceeding Grade 3 according to Engh’s classification. The Ti-Nb-Sn stem with a gradient Young’s modulus provided biomechanical behavior closely resembling in vivo conditions and showed promising clinical results in minimizing stress shielding. These findings support the clinical potential of modulus-graded Ti-Nb-Sn stems for improving implant stability in THA. Full article

Background/Objectives: Femoral or acetabular deformities are important factors in development of early osteoarthritis. In particular, young patients benefit from individual anatomical restoration by decreasing the risk of early loosening and wear and achieving a good clinical outcome. Methods: This prospective study evaluates the use of a custom-made prosthesis in anterior approach total hip arthroplasty (THA). Pre- and postoperative imaging included conventional X-rays as well as computer tomography (CT) with a specialized protocol to analyze femoral diaphysis width, horizontal and vertical offset, caput-collum-diaphyseal (CCD) angle, leg length, femoral and acetabular anteversion angles, and the position of the center of rotation. Results: A total of 22 hips (11 female, 11 male) with a mean age of 55.8 years underwent THA with a custom-made prosthesis (Symbios^®). Accurate restoration has been shown for offset, leg length, and femoral anteversion. The custom stems showed a good fit within the femoral canal. Conclusions: This custom-made prosthesis has been shown to be a valuable option for the treatment of hip osteoarthritis in young patients, with adequate restoration of the preoperative anatomy. Full article

Background: Total elbow arthroplasty (TEA) has evolved over time from a salvage procedure to a successful treatment of end-stage primary and secondary arthritis. However, the aseptic loosening and the associated reduced survival rate are still concerning. Thus, TEA is typically contraindicated in young and active patients where high-demand activities would promote aseptic loosening. For this reason, postoperative weightlifting limitations are often suggested, yet there is no consensus. The aim of this survey was to collect and analyze the current practice concerning the weightlifting restrictions following elbow arthroplasties among members of the Italian Society of Shoulder and Elbow Surgery (Società Italiana Chirurgia Spalla e Gomito, SICSeG). Methods: An online survey on the lifting restrictions after elbow arthroplasties was submitted to all members of the SICSeG. Results: In total, 36 members of the Italian society completed the survey. Only five consultants (13.8%) have experience with all the implants analyzed, of whom only three have experience with more than 10 implants per year. Concerning the comprehensive number of elbow arthroplasties performed per year, most of the respondents (45.7%) reported fewer than five surgeries per year, whereas only two surgeons claimed more than 20 procedures. Of the 36 respondents, 32 (88.9%) reported lifelong lifting limitations after linked TEA. In detail, these lifting restrictions were 10 lb in 14 responders (38.9%) and 5 lb in 15 responders (41.7%) performing linked TEA. A lifelong lifting limitation gradually decreased after unlinked TEA and hemiarthroplasty (HA) being advised by 82.8% (24/36) and 64.5% (20/36), respectively. Conclusions: To increase implant longevity, most Italian surgeons advise lifting restrictions after TEA. More than 80% of the responders agreed with suggesting lifelong limitations, but a greater variability was found in the amount of weight to which the patients are restricted. Currently, the lack of consensus on the optimal weightlifting restrictions after elbow replacements emphasizes the need for more studies focusing on elbow joint loading during different activities of daily life to improve implant survival rates. Full article

Background: Femoroacetabular impingement (FAI) is a frequently observed hip condition among young, active individuals—especially athletes—that can result in pain, restricted mobility, and a heightened risk of osteoarthritis. Hip arthroscopy has increasingly become the preferred surgical approach for managing FAI due to its ability to alleviate symptoms and improve function. However, potential differences in outcomes between athletes and non-athletes have not been thoroughly investigated. This systematic review and meta-analysis compared arthroscopic management for FAI in athletes versus non-athletes. The outcomes of interest were patient-reported outcome measures (PROMs) and complications. Methods: PubMed, Web of Science, and Embase were systematically accessed until October 2024. The studies eligible were clinical investigations comparing athletes and non-athletes undergoing hip arthroscopy for FAI with a minimum follow-up of 24 months. The outcomes assessed included the Visual Analogue Scale (VAS), Hip Outcome Score for Activities of Daily Living (HOS-ADL), and the Hip Outcome Score–Sport-Specific Subscale (HOS-SSS). Data on reoperation rates and progression to total hip arthroplasty were also extracted. The ROBINS-I tool was used to assess the risk of bias, and meta-analyses were performed using Review Manager 5.3. Results: Three comparative investigations, comprising 808 patients (165 athletes and 643 non-athletes), met the inclusion criteria. Baseline characteristics were similar across both groups. The analyses demonstrated no statistically significant differences in the PROMs (VAS: p = 0.7; HOS-ADL: p = 0.5; HOS-SSS: p = 0.4), reoperation rates (p = 0.7), or the rate of progression to arthroplasty (p = 0.4) between athletes and non-athletes. Furthermore, meta-analyses of two studies reinforced the absence of significant differences in VAS and HOS-SSS outcomes. Conclusion: Hip arthroscopy for FAI appears to yield equivalent improvements in pain and functional outcomes for both athletes and non-athletes, with comparable complication rates at an approximate two-year follow-up. Despite the limited number of studies and a moderate risk of bias, the findings support the effectiveness of arthroscopic intervention across varying physical activity levels. Full article

The prototype of a biomimetic multi-spiked connecting scaffold (MSC-Scaffold) represents an essential innovation in the fixation in subchondral trabecular bone of components for a new generation of entirely cementless hip resurfacing arthroplasty (RA) endoprostheses. In designing such a functional biomaterial scaffold, identifying the microstructural and mechanical properties of the host bone compromised by degenerative disease is crucial for proper post-operative functioning and long-term maintenance of the endoprosthesis components. This study aimed to explore, depending on the occurrence of obesity, changes in the microstructure and mechanical properties of the subchondral trabecular bone in femoral heads of osteoarthritis (OA) patients caused by the MSC-Scaffold embedding. Computed microtomography (micro-CT) scanning of femoral heads from OA patients was conducted before and after the mechanical embedding of the MSC-Scaffold. Bone morphometric parameters such as bone volume/total volume (BV/TV), trabecular thickness (Tb.Th), and trabecular number (Tb.N) for regions surrounding the MSC-Scaffold were computed, and the mechanical properties such as bone density (ρ_B), bone compressive strength (S), and the Young’s modulus (E) within these regions were calculated. A statistically significant increase in BV/TV (by 15.0% and 24.9%) and Tb.Th (by 13.1% and 42.5%) and a decrease in Tb.N (by 15.2% and 23.6%) were observed, which translates to an increase in ρ_B (by 15.0% and 24.9%), S (by 28.8% and 49.5%), and E (by 18.0% and 29.8%) in non-obese patients and obese patients, respectively. These changes in properties are favorable for the mechanical loads’ transfer from the artificial joint surface via the MSC-Scaffold to the periarticular trabecular bone of the OA femoral head in the postoperative period. Full article

Background/Objectives: There is no consensus in the literature regarding the optimal treatment for complex proximal humerus fractures (PHFs). The aim of this study is to evaluate the clinical, functional, and radiological outcomes, and complications, associated with the Bilboquet implant in the treatment of PHFs. Methods: The search was conducted from the first description of the Bilboquet device in 1994 to June 2024, across PubMed, Web of Science, and Google Scholar, using specific keywords such as (“Bilboquet” OR “Bilboquet prosthesis” OR “Bilboquet device”) AND (“proximal humerus fracture” OR “shoulder fracture”), along with Boolean operators. The inclusion criteria comprised studies published in English or French that focused on the use of the Bilboquet implant for PHFs. Eligible study designs included case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs evaluating clinical, functional, and radiological outcomes, and complications. Studies that do not contain relevant results to this systematic review, pediatric populations, or the use of alternative implants were excluded. Results: A total of eight studies (235 patients) published between 1996 and 2021 were included. The mean age was 68.6 years (56 to 76.8) in all the studies. The majority of patients, 76.2%, were females, with male patients accounting for only 23.8%. A total of 10 (4.3%) patients had 2-part fractures, 40% of patients had 3-part fractures, and 55.7% of patients had 4-part fractures. The mean follow-up was 36.4 months (25.8–88.7), with a mean constant score of 69.7 (62–78.6). Complications included non-union in 2.65% of cases, avascular necrosis in 19.7%, revision surgery in 5.1%, and protrusion of the staple in 4.3%. Conclusions: Despite limited knowledge of the Bilboquet implant, it shows promise in managing complex PHFs in both young and older adults, with favorable clinical and radiological outcomes. It offers advantages over traditional fixation methods and allows easy conversion to arthroplasty if osteonecrosis occurs. However, the long-term outcomes require further study. While early results are promising, larger randomized studies are needed to confirm its broader clinical utility. Full article

Background: Total hip arthroplasty (THA) is a well-established and effective treatment for advanced osteoarthritis (OA) of the hip joint. While commonly performed in older patients, THA is increasingly used in younger individuals, especially in cases of secondary coxarthrosis. Technological advances have led to the development of specialized implants, which allow surgeons to address severe post-inflammatory or dysplastic deformities. Younger patients undergoing THA, often in their 20s or 30s, present higher functional expectations. Despite limited long-term studies, research indicates a higher rate of revision surgeries in this age group compared to older populations, making these procedures a unique challenge. Methods: This retrospective study analyzed 5263 primary total hip arthroplasties (THAs) performed at our center between May 1985 and December 2016. After excluding cemented and hybrid implants, as well as patients lost to follow-up or with other etiologies, 101 uncemented THA procedures in 92 patients aged 30 years or younger were included. The majority (64.4%) were due to dysplastic coxarthrosis (DDH), while avascular necrosis (26.7%) and juvenile rheumatoid arthritis (8.9%) accounted for the rest. The average patient age was 25.6 years, with a mean follow-up period of over 24 years. Surgical technique involved the anterolateral approach, with implants placed in the true acetabular region. Implants included Munich/Plasmacup, Mittelmeier, and P-M designs. Implant survival was estimated using the Kaplan–Meier estimator to determine the probability of implant longevity over the follow-up period. Outcomes were assessed using Merle d’Aubigné and Postel scores, modified by Charnley, alongside radiographic evaluations based on the Crowe, De Lee, and Gruen classifications. Results: Preoperatively radiological assessment of all hips was classified as grade IV according to the Kellgren–Lawrence scale. Over an average follow-up of 24 years, final outcomes using the modified Merle d’Aubigné and Postel (MAP) classification were excellent in 24%, good in 37%, satisfactory in 8%, and poor in 32% of cases. Results compared between DDH group and control group indicate significantly more poor results for the DDH group compared to the control group (p-value < 0.05). All poor outcomes were associated with prosthesis loosening, primarily involving P-M and Mittelmeier acetabular components. Complications included intraoperative fractures in five cases, peripheral nerve dysfunction in six cases, and heterotopic ossification in eight cases. Postoperative pain scores on the VAS scale improved from 6.8 to 1.7. The Kaplan–Meier estimator indicated 10-year survival rates of 85.2% for the entire prosthesis, with 69.8% survival at 15 years and 54.5% at 20 years. For each period the bio-functionality according to Kaplan–Meier estimator was in favor of the control group. Conclusions: Cementless THA in patients aged 30 or younger has demonstrated itself to be an efficacious treatment for hip osteoarthritis, yielding favorable bio-functional outcomes in both short- and long-term follow-up. Nevertheless, THA performed in the context of developmental dysplasia of the hip (DDH) carries a significantly elevated risk of postoperative complications, most notably aseptic loosening, which critically undermines implant survival rates. Given the young demographic and the anticipated prolonged functional lifespan of the prosthesis, there is an increased propensity for loosening over time, necessitating vigilant and sustained postoperative surveillance. Full article