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Luigi Zagra

  • Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

  • A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

  • The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at

Luigi Zagra and Enrico Gallazzi

  • Total hip arthroplasty (THA) is widely considered one of the most successful surgical procedures in orthopaedics. It is associated with high satisfaction rates and significant improvements in quality of life following surgery. On the other hand, the main cause of late revision is osteolysis and wear, often a result of failure of bearing surfaces.

  • Currently, several options are available to the surgeon when choosing the bearing surface in THA (ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoPE), metal-on-polyethylene (MoPE)), each with advantages and drawbacks.

  • Very few studies have directly compared the various combinations of bearings at long-term follow-up. Randomized controlled trials show similar short- to mid-term survivorship among the best performing bearing surfaces (CoC, CoXLPE and MoXLPE). Selection of the bearing surface is often ‘experience-based’ rather than ‘evidence-based’.

  • The aim of this paper is therefore to evaluate the main advantages and drawbacks of various types of tribology in THA, while providing practical suggestions for the surgeon on the most suitable bearing surface option for each patient.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180300.

Luca Pierannunzii and Luigi Zagra

  • Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty.

  • Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips.

  • Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases.

  • Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting.

  • Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.

Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025

Georgios Tsikandylakis, Soren Overgaard, Luigi Zagra, and Johan Kärrholm

  • Choice of articulating materials, head size and the design of the articulation will become decisive for the long-term performance of a total hip arthroplasty (THA) and especially in terms of risk for dislocation and wear-related problems. Here we account for common alternatives based on available studies and the evidence that can be derived from them.

  • Metal or ceramic femoral heads articulating against a liner or cup made of highly cross-linked polyethylene and ceramic-on-ceramic articulations have about similar risk for complications leading to revision, whereas the performance of metal-on-metal articulations, especially with use of big heads, is inferior. The clinical significance of problems related to ceramic-on-ceramic articulations such as squeaking remains unclear. With use of current technology ceramic fractures are rare.

  • Large femoral heads have the potential to increase the range of hip movement before impingement occurs and are therefore expected to reduce dislocation rates. On the other hand, issues related to bearing wear, corrosion at the taper-trunnion junction and groin pain may arise with larger heads and jeopardize the longevity of THA. Based on current knowledge, 32-mm heads seem to be optimal for metal-on-polyethylene bearings. Patients with ceramic-on-ceramic bearings may benefit from even larger heads such as 36 or 40 mm, but so far there are no long-term reports that confirm the safety of bearings larger than 36 mm.

  • Assessment of lipped liners is difficult because randomized studies are lacking, but retrospective clinical studies and registry data seem to indicate that this liner modification will reduce the rate of dislocation or revision due to dislocation without clear evidence of clinically obvious problems due to neck-liner impingement.

  • The majority of studies support the view that constrained liners and dual mobility cups (DMC) will reduce the risk of revision due to dislocation both in primary and revision THA, the latter gaining increasing popularity in some countries. Both these devices suffer from implant-specific problems, which seem to be more common for the constrained liner designs. The majority of studies of these implants suffer from various methodological problems, not least selection bias, which calls for randomized studies preferably in a multi-centre setting to obtain sufficient power. In the 2020s, the orthopaedic profession should place more effort on such studies, as has already been achieved within other medical specialties, to improve the level of evidence in the choice of articulation when performing one of the most common in-hospital surgical procedures in Europe.

Cite this article: EFORT Open Rev 2020;5:763-775. DOI: 10.1302/2058-5241.5.200002

Fabio D’Angelo, Luca Monestier, and Luigi Zagra

  • Treatment of bacterial septic arthritis in the native adult hip joint can be challenging. Prompt diagnosis and treatment decisions can reduce the associated morbidity and mortality.

  • For this systematic review of the literature, we asked: (1) What are the treatment options? (2) What are the success rates and the outcomes after treatment? (3) Which antibiotic and duration of therapy are optimal?

  • We searched the electronic databases PubMed, Scopus, and Embase using the search terms “hip” or “native hip” and “septic arthritis” or “coxitis”. Studies were included if they reported on: (1) bacterial infection of the hip, (2) treatment, (3) success rate/outcomes, (4) follow-up. The final review included 19 studies. The quality of study reporting was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.

  • Three treatment options are: arthroscopy, single open surgery, and two-stage total hip arthroplasty (THA). A high success rate in infection eradication was reported for all three. Intravenous antibiotic therapy should be promptly initiated to eradicate septic arthritis and minimize potential sequelae and complications.

  • Arthroscopy, single open or two-stage THA were reported to be effective in treating bacterial septic arthritis of the native hip. The key to optimal outcome is early diagnosis and timely treatment.

Cite this article: EFORT Open Rev 2021;6:164-172. DOI: 10.1302/2058-5241.6.200082

Giuseppe Solarino, Giovanni Vicenti, Massimiliano Carrozzo, Guglielmo Ottaviani, Biagio Moretti, and Luigi Zagra

  • Modular neck (MN) implants can restore the anatomy, especially in deformed hips such as sequelae of development dysplasia.

  • Early designs for MN implants had problems with neck fractures and adverse local tissue, so their use was restricted to limited indications.

  • Results of the latest generation of MN prostheses seem to demonstrate that these problems have been at least mitigated.

  • Given the results of the studies presented in this review, surgeons might consider MN total hip arthroplasty (THA) for a narrower patient selection when a complex reconstruction is required.

  • Long MN THA should be avoided in case of body mass index > 30, and should be used with extreme caution in association with high offset femoral necks with long or extra-long heads. Cr-Co necks should be abandoned, in favour of a titanium alloy connection.

  • Restoring the correct anatomic femoral offset remains a challenge in THA surgeries.

  • MN implants have been introduced to try to solve this problem. The MN design allows surgeons to choose the appropriate degree and length of the neck for desired stability and range of motion.

Cite this article: EFORT Open Rev 2021;6:751-758. DOI: 10.1302/2058-5241.6.200064

Karl Stoffel, Tamara Horn, Luigi Zagra, Michael Mueller, Carsten Perka, and Henrik Eckardt

  • 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

Christiaan P. van Lingen, Luigi M. Zagra, Harmen B. Ettema, and Cees C. Verheyen

  • Large-head metal-on-metal (MoM) bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing (HR), followed closely by large metal head total hip arthroplasty (THA). A worldwide increase in the use of MoM hip arthroplasty subsequently saw a sharp decline, due to serious complications.

  • MoM was rapidly adopted in the early 2000s until medical device alerts were issued by government regulatory agencies and national and international organisations, leading to post-marketing surveillance and discontinuation of these implants.

  • Guidelines for MoM hip implant follow-up differ considerably between regulatory authorities worldwide; this can in part be attributed to missing or conflicting evidence.

  • The authors consider that the use of large-head MoM THA should be discontinued. MoM HR should be approached with caution and, when considered, should be used only in patients who meet all of the recommended selection criteria, which limits its indications considerably.

  • The phased introduction of new prostheses should be mandatory in future. Close monitoring of outcomes and long-term follow-up is also necessary for the introduction of new prostheses.

Cite this article: van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: current status and future prospects. EFORT Open Rev 2016;1:345-353. DOI: 10.1302/2058-5241.1.160014.

Luigi Zagra, Francesco Benazzo, Dante Dallari, Francesco Falez, Giuseppe Solarino, Rocco D’Apolito, and Claudio Carlo Castelli

  • Hip, spine, and pelvis move in coordination with one another during activity, forming the lumbopelvic complex (LPC).

  • These movements are characterized by the spinopelvic parameters sacral slope, pelvic tilt, and pelvic incidence, which define a patient’s morphotype.

  • LPC kinematics may be classified by various systems, the most comprehensive of which is the Bordeaux Classification.

  • Hip–spine relationships in total hip arthroplasty (THA) may influence impingement, dislocation, and edge loading.

  • Historical ‘safe zones’ may not apply to patients with impaired spinopelvic mobility; adjustment of cup inclination and version and stem version may be necessary to achieve functional orientation and avert complications.

  • Stem design, bearing surface (including dual mobility), and head size are part of the armamentarium to treat abnormal hip–spine relationships.

  • Special attention should be directed to patients with adult spine deformity or fused spine because they are at increased risk of complications after THA.