• The majority of periprosthetic femoral fractures are treated surgically.

• Surgical treatment may be revision only, revision in combination with open reduction and internal fixation (ORIF), or ORIF only.

• The treatment decision is dependent on whether the stem is loose or not, but loose stems are not always identified, resulting in unsatisfactory treatments.

• This article presents an algorithmic approach to identifying loose stems around proximal femoral periprosthetic fractures, taking patient history, stem design, and plain radiographs into consideration. This approach may help identifying loose stems and increase the probability of effective treatments.

Cite this article: EFORT Open Rev 2020;5:449-456. DOI: 10.1302/2058-5241.5.190086

• Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing.

• A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations.

• The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures.

• Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure.

• In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion.

• Most studies comparing distally locked and unlocked nails report a short follow-up.

• Distal locking mode should be based on the fracture’s stability.

Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045

• Cemented implant fixation design principles have evolved since the 1950s, and various femoral stem designs are currently in use to provide a stable construct between the implant–cement and cement–bone interfaces.

• Cemented stems have classically been classified into two broad categories: taper slip or force closed, and composite beams or shaped closed designs. While these simplifications are acceptable general categories, there are other important surgical details that need to be taken into consideration such as different broaching techniques, cementing techniques and mantle thickness.

• With the evolution of cemented implants, the introduction of newer implants which have hybrid properties, and the use of different broaching techniques, the classification of a very heterogenous group of implants into simple binary categories becomes increasingly difficult. A more comprehensive classification system would aid in comparison of results and better understanding of the implants’ biomechanics.

• We review these differing stem designs, their respective cementing techniques and geometries. We then propose a simple four-part classification system and summarize the long-term outcomes and international registry data for each respective type of cemented prosthesis.

Cite this article: EFORT Open Rev 2020;5:241-252. DOI: 10.1302/2058-5241.5.190034

• Human immunodeficiency virus (HIV) is a pandemic affecting more than 35 million people worldwide. The aim of this review is to describe the association between HIV and total hip arthroplasty (THA) and assess patient risk factors to optimize functional outcomes and decrease rates of revision.

• Since the advent of highly active antiretroviral treatment (HAART), HIV-infected patients are living longer, which allows them to develop degenerative joint conditions. HIV and HAART act independently to increase the demand for THA. HIV-positive patients are also more predisposed to developing avascular necrosis (AVN) of the hip and femoral neck fractures due to decreased bone mineral density (BMD).

• Prior to the widespread implementation of access to HAART in homogenous cohorts of HIV-infected patients undergoing THA, reports indicated increased rates of complications. However, current literature describes equivocal functional outcomes and survival rates after THA in HIV-positive patients controlled on HAART when compared to HIV-negative controls.

• HIV-infected patients eligible for THA should be assessed for medical co-morbidities and serum markers of disease control should be optimized.

• Periprosthetic joint infection (PJI) is a leading cause of revision THA, and HIV is a modifiable risk factor. Importantly, the significance is negated once patients are placed on HAART and achieve viral suppression.

• THA should not be withheld in HIV-infected patients injudiciously. However, HIV is a burgeoning epidemic and all patients should be identified and started on HAART to avoid preventable peri-operative complications.

Cite this article: EFORT Open Rev 2020;5:164-171. DOI: 10.1302/2058-5241.5.190030

• Total hip arthroplasty (THA) in sickle cell disease (SCD) patients can be a challenging procedure.

• This systematic review evaluated the revision rate, functional outcomes and complications of THA in sicklers.

• A systematic search was conducted according to the PRISMA guidelines, using four search engines from inception to May 2019.

• Fifteen studies with 971 THAs were included. There were 437 cemented and 520 uncemented THAs.

• There were 164 revision THAs (16.8%); 52 uncemented and 105 cemented THAs.

• Forty-two infections were recorded; 16 infections for cemented and 23 for uncemented THAs.

• Fifty-seven cups, 26 stems, eight cup/stem with aseptic loosening that were more frequently cemented were reported. The 28 unspecified aseptic loosening cases were more frequently uncemented THAs.

• All studies demonstrated the functional improvement of patients.

• There were 109 medical complications (14.3%). Sickle cell crises (SCC) and transfusion reactions were most usually recorded.

• Forty-six intraoperative complications (4.7%) were reported; 18 femoral fractures, four acetabular and 18 femoral perforations. Seventeen femoral fractures occurred during uncemented THA.

• THA in SCD is still related to a high risk of complications. The outcomes in properly selected sicklers have been improved. Perioperative adequate hydration, warming, oxygen supply and transfusion protocols are mandated to prevent SCC and transfusion reactions. The surgeon must be prepared to deal with a high rate of intraoperative fractures and have different implant options readily available. No definite conclusion can be made regarding the best fixation mode. Cemented implants demonstrated a higher revision rate and uncemented implants a higher risk for intraoperative complications.

Cite this article: EFORT Open Rev 2020;5:180-188. DOI: 10.1302/2058-5241.5.190038

• This review article presents a comprehensive literature review regarding extended trochanteric osteotomy (ETO).

• The history, rationale, biomechanical considerations as well as indications are discussed.

• The outcomes and complications as reported in the literature are presented, discussed and compared with our own practice.

• Based on the available evidence, we present our preferred technique for performing ETO, its fixation, as well as post-operative rehabilitation.

• The ETO aids implant removal and enhanced access. Reported union rate of ETO is high. The complications related to ETO are much less frequent than in cases when accidental intra-operative femoral fracture occurred that required fixation.

• Based on the literature and our own experience we recommend ETO as a useful adjunct in the arsenal of the revision hip specialist.

Cite this article: EFORT Open Rev 2020;5:104-112. DOI: 10.1302/2058-5241.5.190005

• Prosthetic loosening has been debated for decades, both in terms of the timing and nature of the triggering events. Multiple radiostereometric studies of hip prostheses have now shown that early migration poses a risk of future clinical failure, but is this enough to explain late clinical loosening?

• To answer this question, the progression of loosening from initiation to radiographic detection is described; and the need for explanations other than early prosthetic loosening is analysed, such as stress-shielding, particle disease, and metal sensitivity.

• Much evidence indicates that prosthetic loosening has already been initiated during or shortly after the surgery, and that the subsequent progression of loosening is affected by biomechanical factors, fluid pressure fluctuations and inflammatory responses to necrotic cells and cell fragments, i.e. the concept of late loosening appears to be a misinterpretation of late-detected loosening.

• Clinical implications: atraumatic surgery and initial prosthetic stability are crucial in ensuring low risk of prosthetic loosening.

Cite this article: EFORT Open Rev 2020;5:113-117. DOI: 10.1302/2058-5241.5.190014

• Hip fractures are severe conditions with a high morbidity and mortality, especially when the diagnosis is delayed, and if formulated over 30 days after the injury, is termed a ‘neglected femoral neck fracture’ (NFNF).

• Cerebral palsy (CP) is probably one of the major risk factors for NFNF in Western countries, mainly because of both cognitive and motor impairments. However, considering the high prevalence of fractures in these patients, the incidence of NFNF in this population is probably underestimated, and this condition might result in persistent hip or abdominal pain.

• Several techniques are available for the treatment of NFNF (i.e. muscle pedicle bone graft, fixation with fibular graft, valgisation osteotomy), but most of them could affect motor function.

• Motor function must be preserved for as long as possible, in order to enhance the quality of life of CP patients.

• After discussing published NFNF cases in CP patients and available treatment options, a practical approach is proposed to facilitate the orthopaedic surgeon to both early identify and appropriately manage these challenging fractures.

Cite this article: EFORT Open Rev 2020;5:58-64. DOI: 10.1302/2058-5241.5.190019

• Excessive anterior pelvic tilt is suspected of causing femoroacetabular impingement, low back pain, and sacroiliac joint pain. Non-surgical treatment may decrease symptoms and is seen as an alternative to invasive and complicated surgery. However, the effect of non-surgical modalities in adults is unclear. The aim of this review was to investigate patient- and observer-reported outcomes of non-surgical intervention in reducing clinical symptoms and/or potential anterior pelvic tilt in symptomatic and non-symptomatic adults with excessive anterior pelvic tilt, and to evaluate the certainty of evidence.

• MEDLINE, EMBASE, Web of Science and Cochrane (CENTRAL) databases were searched up to March 2019 for eligible studies. Two reviewers assessed risk of bias independently, using the Cochrane Risk of Bias tool for randomized trials and the ROBINS-I tool for non-randomized studies. Data were synthesized qualitatively. The GRADE approach was used to assess the overall certainty of evidence.

• Of 2013 citations, two randomized controlled trials (RCTs) (n = 72) and two non-RCTs (n = 23) were included. One RCT reported a small reduction (< 2°) in anterior pelvic tilt in non-symptomatic men. The two non-RCTs reported a statistically significant reduction in anterior pelvic tilt, pain, and disability in symptomatic populations. The present review was based on heterogeneous study populations, interventions, and very low quality of evidence.

• No overall evidence for the effect of non-surgical treatment in reducing excessive anterior pelvic tilt and potentially related symptoms was found. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted.

Cite this article: EFORT Open Rev 2020;5:37-45. DOI: 10.1302/2058-5241.5.190017

• Osteonecrosis of the femoral head is a poorly understood condition that may lead to progressive destruction of the hip joint. Its incidence is common between the third and fifth decades of life and it is the diagnosis behind 5–18% of annually performed total hip arthroplasties (THAs) in the USA.

• Regarding the high rate of complications of THA in that age group, authors have agreed on the importance of joint-preservation techniques for this disease but techniques vary to establish a generally accepted algorithmic approach.

• Surgical head-preserving procedures, core decompression with or without graft, stem cell augmentation, or biologic adjuncts, vascularized bone grafting, and proximal femoral osteotomies have all been published on with heterogeneous results and with limited evidence to date.

• Consensus states that the prognosis of patients with osteonecrosis of the femoral head can be significantly improved with early diagnosis and timely intervention.

Cite this article: EFORT Open Rev 2019;4:647-658. DOI: 10.1302/2058-5241.4.180073