IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via Magliotto 2, Savona, Italy
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IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
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Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via Magliotto 2, Savona, Italy
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The number of primary total hip arthroplasties (THAs) and revisions is expected to steadily grow in the future. The femoral revision surgery can be technically demanding whether severe bone defects need to be addressed.
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The femoral revision aims to obtain a proper primary stability of the stem with a more proximal fixation as possible. Several authors previously proposed classification systems to describe the morphology of the bony femoral defect and to drive accordingly the surgeon in the revision procedure.
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The previous classifications mainly considered cortical and medullary bone at the level of the defect of poor quality by definition. Therefore, the surgical strategies aimed to achieve a distal fixation bypassing the defect or to fill the defect with bone impaction grafting or structured bone grafts up to the replacement of the proximal femur with megaprosthesis.
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The consensus on a comprehensive and reliable classification system and management algorithm is still lacking. A new classification system should be developed taking into account the bone quality. The rationale of a new classification is that ‘functional’ residual bone stock could be present at the level of the defect. Therefore, it can be used to achieve a primary (mechanical) and secondary (biological) stability of the implants with a femoral fixation more proximal as possible.
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Aim
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The aim of this study was to provide a comprehensive overview of floating hip injury and attempt to provide a management algorithm.
Methods
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PubMed was searched using the terms ‘Floating hip’ or ‘acetabular fracture’ and ‘Ipsilateral femoral fracture’ or ‘pelvic fracture’ and ‘Ipsilateral femoral fracture’. One author performed a preliminary review of the abstracts and references of the retrieved articles.
Results
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The mean injury severe score reported was higher than 20. Chest and abdominal injuries, as well as fractures at other sites, were the most common associated injuries. Despite the high disability rate, surgery remained the preferred option for managing these injuries. The surgical timing varied from a few hours to several days and was subjected to the principles of damage control orthopedics. Although, in most cases, fixation of femoral fractures took precedence over pelvic or acetabular fractures, there was still a need to consider the impact of damage control orthopedics, associated injuries, and surgeon's considerations and preferences. Posttraumatic arthritis, neurological deficits, heterotopic ossification, femoral head necrosis, femoral nonunion, and limb inequality were common complications of the floating hip injury.
Conclusions
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The severity of such injuries often exceeds that of an isolated injury and often requires specialized multidisciplinary treatment. In the management of these complex cases, the complexity and severity of the injury should be fully assessed, and an appropriate surgical plan should be developed to perform definitive surgery as early as possible, with attention to prevention of complications during the perioperative period.
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via
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Department of Orthopaedics and Traumatology, IRCCS Fondazione Policlinico San Matteo, University of Pavia, Pavia, Italy
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Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Universidad Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
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Department of Trauma and Orthopaedic Surgery, Hospital Nostra Senyora de Meritxell, Andorra
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Universidad de Valladolid, Valladolid, Spain
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Universidad Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
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A peri-implant femoral fracture (PIFF) is defined as a femoral fracture in the presence of a pre-existing non-prosthetic implant. Classification systems, treatment guidelines and fixation strategies exist for peri-prosthetic fractures, but there is no standard of care regarding PIFFs.
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The aim of the Peri-Implant Spanish Consensus (aka PISCO) investigators is to reach an agreement regarding current practices for management of PIFFs and to propose four main principles to assess surgical treatment and prevention of these fractures.
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This consensus review was conducted according to the Delphi method. Twenty-two expert orthopaedic trauma surgeons performed the consensus and the definitive statements were approved unanimously.
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Biological fixation principles must be utilized in the surgical treatment of peri-implant femur fractures, which include closed or minimally invasive reduction techniques. The osteosynthesis must protect the entire bone.
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Gaps between two implants should be avoided. If implant overlap is not possible to achieve, then spanning inter-implant fixation systems must be used, especially in osteoporotic bone.
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Previous implants should be retained during surgical treatment of peri-implant femur fractures. Only those implants that would interfere with current fixation goals should be removed.
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If the previous implant is in the femoral neck region, then femoral neck protection must be maintained when treating the peri-implant fracture, even if the neck fracture has already healed.
Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, USA
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Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, USA
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With the growing number of primary arthroscopies performed, patients requiring revision hip arthroscopies for various issues is high including postoperative adhesion formation, a source of pain, mechanical symptoms, range of motion limitation, stiffness, and microinstability.
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Adhesions are a consequence of biological pathways that have been stimulated by injury or surgical interventions leading to an increased healing response.
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Preventative efforts have included surgical adjuncts during/after primary hip arthroscopy, biologic augmentation, and postoperative rehabilitation.
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Treatment options for adhesion formation includes surgical lysis of adhesions with or without placement of biologic membranes aimed at inhibiting adhesion reformation as well as systemic medications to further reduce the risk.
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Postoperative rehabilitation exercises have also been demonstrated to prevent adhesions as a result of hip arthroscopy. Ongoing clinical trials are further investigating pathways and prevention of adhesion formation.
Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Thessaloniki, Greece
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Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Thessaloniki, Greece
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Department of Trauma and Orthopaedics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Thessaloniki, Greece
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Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Thessaloniki, Greece
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Purpose
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The main indication of bisphosphonates (BPs) is osteoporosis treatment. However, there is growing interest in the peri- and postoperative use of BPs to mitigate total hip arthroplasty (THA) aseptic loosening (AL) risk. This systematic review aimed to evaluate the implant survival and the AL rate in patients with elective THA receiving BPs compared to those that do not receive BPs. Secondary outcomes included the comparison of revision rate, postoperative complications, and patients’ functional scores.
Methods
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This systematic review was conducted under the PRISMA 2020 guidelines with a pre-registered PROSPERO protocol. Three engines and grey literature were searched up until May 2022. Randomized and nonrandomized controlled trials and comparative cohort studies assessing BP and control therapy impact on THA survival were included.
Results
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Twelve studies embraced the inclusion criteria. A total of 99 678 patients and 99 696 THAs were included; 10 025 patients received BPs (BP group), and 89 129 made up the control group. The overall revision and AL rates were lower in the BP group (2.17% and 1.85%) than in the control group (4.06% and 3.2%). Periprosthetic fracture (PPF) cases were higher in the BP group (0.24%) than in the control group (0.04%); however, the majority of PPF cases were derived from a single study. Further complication risk was similar between groups. Most studies reported comparable functional scores between groups.
Conclusion
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BP treatment after elective THA seems to reduce the overall revision and AL risk. Other complications’ risk and functional scores were similar between groups. Further high-quality studies are needed to validate the results due to the multifactorial AL pathogenesis.
Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
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Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
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Institute of Orthopaedics and Musculoskeletal Science, University College London, United Kingdom
Cleveland Clinic London, United Kingdom
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CT is the principal imaging modality used for the pre-operative 3D planning and assessment of total hip arthroplasty (THA).
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The image quality offered by CT has a radiation penalty to the patient. Higher than necessary radiation exposure is of particular concern when imaging young patients and women of childbearing age, due to the greater risk of radiation-induced cancer in this group.
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A harmonised low-dose CT protocol is needed, evidenced by the huge variability in the 17 protocols reviewed. The majority of the protocols were incomplete, leading to uncertainty among radiographers when performing the scans.
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Only three protocols (20%) were optimised for both ‘field of view’ and image acquisition parameters. 10 protocols (60%) were optimised for ‘field of view’ only. These protocols included imaging of the relevant landmarks in the bony pelvis in addition to the knees – the reference for femoral anteversion.
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CT parameters, including the scanner kilovoltage (kV), milliamperage–time product (mAs) and slice thickness, must be optimised with a ‘field of view’ that includes the relevant bony landmarks. The recommended kV and mAs values were very wide ranging from 100 to 150 and from 100 to 250, respectively.
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The large variability that exists amongst the CT protocols illustrates the need for a more consistent low-dose CT protocol for the planning of THA. This must provide an optimal balance between image quality and radiation dose to the patient.
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Current CT scanners do not allow for measurements of functional pelvic orientation and additional upright imaging modalities are needed to augment them.
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Department of Occupational Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung City, Taiwan
Department of Biomedical Engineering, I-Shou University, Kaohsiung City, Taiwan
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Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
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Purpose
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Comminuted fractures with poor bone quality in the elderly are associated with poor outcomes. An alternative to open reduction and internal fixation (ORIF) alone, primary or acute total hip arthroplasty (aTHA), allows early mobilization with full weight bearing. In this study, we aim to analyze whether treatment of aTHA with/withtout ORIF (limited ORIF) vs ORIF alone yields better intra-operative results, functional outcomes, and less complications.
Methods
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PubMed, Cochrane, Embase, and Scopus databases were searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Random-effects model and 95% confidence intervals were used. The outcomes of interest were surgery time, blood loss, length of hospital stay, Harris hip score (HHS), 36-Item Short Form Survey (SF-36), complication rate, surgical site infection rate, heterotopic ossification rate, reoperation rate, and mortality rate.
Results
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Ten observational studies with a total of 642 patients (415 ORIF alone and 227 aTHA with/without ORIF) were included in the systematic review. Compared to ORIF alone, aTHA with limited ORIF provided higher HHS (P = 0.029), better physical function (P = 0.008), better physical component summary (P = 0.001), better mental component summary (P = 0.043) in postoperative 1-year SF-36, lesser complication rate (P = 0.001), and lesser reoperation rate (P = 0.000), but however greater bodily pain (P = 0.001) in acetabular fractured elderlies.
Conclusions
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Acute THA with limited ORIF is favorable alternative to ORIF technique alone. It provided better HHS, physical, and mental component summary in SF-36 and yielded lower complication and reoperation rate compare to ORIF alone.
