• The prognosis of sickle cell disease (SCD) has greatly improved in recent years, resulting in an increased number of patients reporting musculoskeletal complications such as osteonecrosis of the femoral head. Total hip arthroplasty (THA) can be utilized to alleviate the pain associated with this disease.

• Although it is well known that hip arthroplasty for avascular necrosis (AVN) in SCD may represent a challenge for the surgeon, complications are frequent, and no guidelines exist to prevent these complications. Because patients with SCD will frequently undergo THA, we thought it necessary to fulfil the need for guidance recommendations based on experience, evidence and agreement from the literature.

• For all these reasons this review proposes guidelines that provide clinicians with a document regarding management of patients with SCD in the period of time leading up to primary THA. The recommendations provide guidance that has been informed by the clinical expertise and experience of the authors and available literature.

• Although this is not a systematic review since some papers may have been published in languages other than English, our study population consisted of 5,868 patients, including 2,126 patients with SCD operated on for THA by the senior author in the same hospital during 40 years and 3,742 patients reported in the literature.

Cite this article: EFORT Open Rev 2020;5:641-651. DOI: 10.1302/2058-5241.5.190073

• Pelvic motion acting as a hinge between the spine and hips is essential to maintain proper balance during bipedalism. Pelvic rotation is recruited as a compensation mechanism when spinal malalignment occurs.

• This pelvic rotation can affect functional acetabular orientation, and consequently functional cup positioning if a total hip arthroplasty (THA) is needed. Pelvic retroversion, frequently associated with degenerative spinal changes, implies an increase of acetabular version.

• Patients with flexible lumbar spines (spine users) protect the hip joint. Patients with stiff, degenerated or fused lumbar spines (hip users) demand higher hip mobility, placing the THA at risk.

• Pelvises in retroversion place the THA at risk for anterior dislocation when standing. In contrast, pelvises in anteversion or with low pelvic incidence (PI) can place THA at risk for posterior dislocation when sitting.

• Try to set the cup in an anatomic position. However, bear in mind that low PI pelvises may need more acetabular ante-inclination, and high PI pelvises more acetabular retroversion.

• If surgery is needed, start first by addressing the hip, except in patients with compensation (high pelvic retroversion), who may need spine surgery first to place the pelvis, and consequently the acetabulum, in a proper position.

Cite this article: EFORT Open Rev 2020;5:522-533. DOI: 10.1302/2058-5241.5.200032

• The rising incidence of postoperative periprosthetic femoral fracture (PFF) presents a significant clinical and economic burden.

• A detailed understanding of risk factors is required in order to guide preventative strategies.

• Different femoral stems have unique characteristics and management strategies must be tailored appropriately.

• Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems.

• Future research should focus on implant-related risk factors, treatment of concurrent metabolic bone disease and the use of large endoprostheses.

Cite this article: EFORT Open Rev 2020;5:558-567. DOI: 10.1302/2058-5241.5.200003

• Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

• Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

• Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

• Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

• Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

• There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

• Trochanteric osteotomy is a technique that allows expanded exposure and access to the femoral canal and acetabulum for a number of indications.

• There has been renewed interest in variants of this technique, including the trochanteric slide osteotomy (TSO), extended trochanter osteotomy (ETO), and the transfemoral approach, for both septic and aseptic revision total hip arthroplasty (THA).

• Osteotomy fixation is crucial for achieving union, and wire and cable-plate systems are the most common techniques.

• TSO involves the creation of a greater trochanter fragment with preserved abductor attachment proximally and vastus lateralis attachment distally.

• This technique may be particularly useful in the setting of abductor deficiency or when augmented acetabular exposure is needed.

• ETO is a posterior-laterally based extensile approach that has been successfully utilized for aseptic and septic indications; most series report a greater than 90% rate of union.

• The transfemoral approach, as known as the Wagner osteotomy, is an extensile femoral approach and is more anterior-based than the alternate posterior-based ETO. It may be particularly useful for anterior-based approaches and anterior femoral remodelling; rates of union after this approach in most reports have been close to 100%.

Cite this article: EFORT Open Rev 2020;5:477-485. DOI: 10.1302/2058-5241.5.190063

• 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