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George Grammatopoulos, Moritz Innmann, Philippe Phan, Russell Bodner, and Geert Meermans

  • There is no universal safe zone for cup orientation. Patients with spinal arthrodesis or a degenerative lumbar spine are at increased risk of dislocation.

  • The relative contributions of the hip (femur and acetabulum) and of the spine (lumbar spine) in body motion must be considered together. The pelvis links the two and influences both acetabular orientation (i.e. hip flexion/extension) and sagittal balance/lumbar lordosis (i.e. spine flexion/extension).

  • Examination of the spino-pelvic motion can be done through clinical examination and standard radiographs or stereographic imaging. A single, lateral, standing spinopelvic radiograph would be able to providemost relevant information required for screening and pre-operative planning.

  • A significant variability in static and dynamic spinopelvic characteristics exists amongst healthy volunteers without known spinal or hip pathology.

  • The stiff, arthritic, hip leads to greater changes in pelvic tilt (changes are almost doubled), with associated obligatory change in lumbar lordosis to maintain upright posture (lumbar lordosis is reduced to counterbalance for the reduction in sacral slope). Following total hip arthroplasty and restoration of hip flexion, spinopelvic characteristics tend to change/normalize (to age-matched healthy volunteers).

  • The static spinopelvic parameters that are directly associated with increased risk of dislocation are lumbo-pelvic mismatch (pelvic incidence – lumbar lordosis angle >10°), high pelvic tilt (>19°), and low sacral slope when standing. A high combined sagittal index (CSI) when standing (>245°) is associated with increased risk of anterior instability, whilst low CSI when standing (<205°) is associated with increased risk of posterior instability.

  • Aiming to achieve an optimum CSI when standing within 205–245° (with narrower target for those with spinal disease) whilst ensuring the coronal targets of cup orientation targets are achieved (inclination/version of 40/20 ±10°) is our preferred method.

Peter Luca DiGiovanni, Xavier Gasparutto, Stéphane Armand, and Didier Hannouche

  • Offsets in the frontal plane are important for hip function.

  • Research on total hip arthroplasty (THA) surgery agrees that increasing femoral offset up to 5 mm could improve functional outcome measures.

  • The literature indicates that global offset is a key parameter that physicians should restore within 5 mm during surgery and avoid decreasing.

  • Substantiated findings on acetabular offset are lacking despite its recognized importance, and the medialization approach must be assessed in light of its shortcomings.

  • Future research, possibly through improved measurement, unified definitions, patient-specific surgical planning, and technology-enhanced surgical control, with specific focus on acetabular offset, is needed to better understand its impact on THA outcomes.

James R Satalich, Daniel J Lombardo, Simon Newman, Gregory J Golladay, and Nirav K Patel

  • Total hip arthroplasty (THA) is a remarkably successful operation that has grown rapidly its utilization.

  • Early modern THA constructs as developed by Sir John Charnley featured cemented femoral stems and acetabular components. The technique of cementing components for THA has evolved over time.

  • Modern acetabular preparation requires exposure of the subchondral bone with appropriate cement penetration into the trabecular bone, whereas femoral preparation requires cleaning of the canal, cement restrictor placement, retrograde filling, and pressurization of the cement.

  • When used appropriately, these techniques result in excellent long-term survivorship of implants and are also widely considered to be the ideal method of fixation for hip fractures.

  • The purpose of this article to review the history, properties, techniques, and outcomes of bone cement utilization in THA.

Dongmei Wu, Rohan M Bhalekar, Jordan S Marsh, David J Langton, and Alan J Stewart

  • Hip joints with bearings composed of cobalt–chromium alloy (metal-on-metal bearings) have been one of the most widely used implants in joint replacement arthroplasty. Unfortunately, these implants can contribute to a complication called aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), a type IV metal hypersensitivity response around the joint.

  • Consistent with such bearings, increased metal debris can be found in the surrounding fluids and in remote tissues and organs, due to wear and corrosion. It is hypothesized that metal ions released from the prosthesis (including Co2+) can potentially form haptens with proteins such as serum albumin in synovial fluid that in turn elicit ALVAL.

  • Generally, elevated cobalt and chromium levels in synovial fluids may indicate implant failure. However, such measurements cannot be used as a reliable tool to predict the onset of ALVAL. To detect ALVAL, some diagnostic tests, questionnaires and imaging techniques have been used clinically with some success, but a standardized approach is lacking.

  • At present, guidelines for implant usage and patient management are ambiguous and inconsistent across health care authorities. To reduce and better manage the development of ALVAL, further research into the precise molecular mechanism(s) by which ALVAL develops is urgently needed.

  • Identification of diagnostic and prognostic biomarkers for ALVAL is required, as are more standardized guidelines for surgery and patient management.

Andrew J Curley, Ethan R Ruh, Amisha Shah, Ashley E Disantis, April Krivoniak, Craig S Mauro, and Michael P McClincy

  • Bone morphology has been increasingly recognized as a significant variable in the evaluation of non-arthritic hip pain in young adults.

  • Increased availability and use of multidetector CT in this patient population has contributed to better characterization of the osseous structures compared to traditional radiographs.

  • Femoral and acetabular version, sites of impingement, acetabular coverage, femoral head–neck morphology, and other structural abnormalities are increasingly identified with the use of CT scan.

  • In this review, a standard CT imaging technique and protocol is discussed, along with a systematic approach for evaluating pelvic CT imaging in patients with non-arthritic hip pain.

David González-Martín, José Luis Pais-Brito, Sergio González-Casamayor, Ayron Guerra-Ferraz, Jorge Ojeda-Jiménez, and Mario Herrera-Pérez

  • There is currently a debate on whether all Vancouver B2 periprosthetic hip fractures should be revised.

  • The aim of our work was to establish a decision-making algorithm that helps to decide whether open reduction and internal fixation (ORIF) or revision arthroplasty (RA) should be performed in these patients.

  • Relative indications in favour of ORIF are low-medium functional demand (Parker mobility score (PMS) <5), high anaesthetic risk (American Society of Anesthesiologists score (ASA) ≥ 3), many comorbidities (Charlson Comorbidity Index (CCI) ≥ 5), 1 zone fractured (VB2.1), anatomical reconstruction possible, and no prior loosening (hip pain).

  • Relative indications in favour of RA are high functional demand (PMS ≥6), low anaesthetic risk (ASA< 3), few comorbidities (CCI<5), fracture ≥ 2 zones (VB2.2), comminuted fractures, and prior loosening (hip pain).

  • In cemented stems, those fractures with fully intact cement–bone interface, no stem subsidence into the cementraliser, cement mantle anatomically reducible, and some partial stem-cement attachment can be safely treated with ORIF.

Pieter Bas de Witte, Christiaan J A van Bergen, Babette L de Geest, Floor Willeboordse, Joost H van Linge, Yvon M den Hartog, Magritha (Margret) M H P Foreman-van Drongelen, Renske M Pereboom, Simon G F Robben, Bart J Burger, M Adhiambo Witlox, and Melinda M E H Witbreuk

Background and purpose

  • Diagnostics and treatment of developmental dysplasia of the hip (DDH) are highly variable in clinical practice. To obtain more uniform and evidence-based treatment pathways, we developed the ‘Dutch guideline for DDH in children < 1 year’. This study describes recommendations for unstable and decentered hips.

Materials and methods

  • The Appraisal of Guidelines for Research and Evaluation criteria (AGREE II) were applied. A systematic literature review was performed for six predefined guideline questions. Recommendations were developed, based on literature findings, as well as harms/benefits, patient/parent preferences, and costs (GRADE).


  • The systematic literature search resulted in 843 articles and 11 were included. Final guideline recommendations are (i) Pavlik harness is the preferred first step in the treatment of (sub) luxated hips; (ii) follow-up with ultrasound at 3–4 and 6–8 weeks; (iii) if no centered and stable hip after 6–8 weeks is present, closed reduction is indicated; (iv) if reduction is restricted by limited hip abduction, adductor tenotomy is indicated; (v) in case of open reduction, the anterior, anterolateral, or medial approach is advised, with the choice based on surgical preference and experience; (vi) after reduction (closed/open), a spica cast is advised for 12 weeks, followed by an abduction device in case of residual dysplasia.


  • This study presents recommendations on the treatment of decentered DDH, based on the available literature and expert consensus, as Part 2 of the first official and national evidence-based ‘Guideline for DDH in children < 1 year’. Part 1 describes the guideline sections on centered DDH in a separate article.

Geert Meermans, George Grammatopoulos, Moritz Innmann, and David Beverland

  • Acetabular component orientation and position are important factors in the short- and long-term outcomes of total hip arthroplasty.

  • Different definitions of inclination and anteversion are used in the orthopaedic literature and surgeons should be aware of these differences and understand their relationships.

  • There is no universal safe zone.

  • Preoperative planning should be used to determine the optimum position and orientation of the cup and assess spinopelvic characteristics to adjust cup orientation accordingly.

  • A peripheral reaming technique leads to a more accurate restoration of the centre of rotation with less variability compared with a standard reaming technique.

  • Several intraoperative landmarks can be used to control the version of the cup, the most commonly used and studied is the transverse acetabular ligament.

  • The use of an inclinometer reduces the variability associated with the use of freehand or mechanical alignment guides.

Philippe Chiron and Nicolas Reina

  • The smaller the head fragment, the more likely it is located at the bottom and in front of the femoral head, which then determines the most suitable approach.

  • A CT scan is essential after reduction and before resumption of weight-bearing to verify the size and congruence of the fragments and whether there are foreign bodies and/or a fracture of the posterior wall.

  • Classifications should include the size of the fragment and whether or not there is an associated fracture of the acetabulum or femoral neck (historical ‘Pipkin’, modernised ‘Chiron’).

  • In an emergency, the dislocation should be rectified, without completing the fracture (sciatic nerve palsy should be diagnosed before reduction). A hip prosthesis may be indicated (age or associated cervical fracture).

  • Delayed orthopaedic treatment is sufficient if congruence is good. A displaced fragment can be resected (foreign bodies and ¼ head), reduced and osteosynthesised (⅓ and ½ head), and a posterior wall fracture reduced and osteosynthesised. Small fragments can be resected under arthroscopy. The approach is medial (Luddloff, Ferguson, Chiron) to remove or osteosynthesise ⅓ or ¼ fragments; posterior for ½ head or a fractured posterior wall.

  • The results remain quite good in case of resection or an adequately reduced fragment. Long-term osteoarthritis is common (32%) but well tolerated with a low rate of prosthetisation. Avascular necrosis remains a possible complication (8.2%). Sciatic nerve palsy (4% of fracture dislocations) is more common for dislocations associated with posterior wall fractures.

Marilena Giannoudi and Peter V Giannoudis

  • With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy.

  • Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents.

  • Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.