Historical overview of hip arthroplasty: From humble beginnings to a high-tech future.

Surgery of the arthritic hip was not an easy task in the previous centuries, lots of operations being followed very closely by complications and failures. Nowadays, hip arthroplasty is considered "the operation of the century". This review follows the evolution of surgery on the arthritic hip, with emphasis on arthroplasty. Acknowledging the history of this operation, one can better prepare its evolution and future directions of research. The final chapter briefly describes the current trends and future perspectives.

Are physical therapy pain levels affected by surgical approach in total hip arthroplasty? A randomized controlled trial.

The main objective of this study was to evaluate the difference in pain levels during postoperative physical therapy pathways in patients who underwent a cement less total hip replacement either through a muscle sparing direct anterior approach (DAA), or the classic trans-gluteal lateral approach (LA). One hundred and twelve (112) patients were randomized into two equal groups. Baseline values of myoglobin levels were acquired prior to surgery and repeated at 6 hours postoperatively as a biomarker for muscle damage. Pain levels during the first passive and consecutive 3 active physical therapy sessions were noted using a visual analogue-numeric scale (VAS). Pain levels were also acquired at 6 weeks, 3 months, 6 months and 1 year, following a 20-meter (65.6 feet) walking test. Postoperative myoglobin (ng/mL) levels were significantly higher (p< 0.05) in the LA group (335.05±83.54) then the DAA group (237.71±57.54). Pain levels were significantly lower (p<0.001) in the DAA group for both passive (2.5±1.45 vs. 4.28±2.19) and active physical therapy sessions and there was a positive correlation between postoperative myoglobin levels and pain levels until 6 postoperative weeks. There was no significant difference in demographics between the two groups except for gender distribution. The direct anterior approach's main advantage of being a minimally invasive muscle sparing technique is showing a better rehabilitation experience with lower pain levels during passive and active physical therapy when compared to the classic trans-gluteal lateral approach.

Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years.

OBJECTIVE: The aim of this retrospective study was to compare the clinical outcomes of anatomic single bundle ACL reconstruction using either a free quadriceps tendon autograft or a quadrupled hamstring autograft with a minimum follow-up of 24 months. METHODS: Consecutive patients undergoing ACL reconstruction using either a free quadriceps tendon autograft or hamstring tendon autograft from January 2013 to December 2014 were included. ACL reconstruction was done in all patients due to isolated ACL tears. Patients with associated cartilage lesions > Outerbridge III, meniscal lesions in need of meniscectomy or repair as well as patients with prior knee surgery on the affected or contralateral knee were excluded. The primary outcome evaluation was the side-to-side difference in instrumented Lachman testing. Secondary outcome evaluation consisted in the Lysholm, modified Cincinnati and SF-36 scores. Side-to-side difference in range of motion and thigh diameter was also documented. RESULTS: After applying the inclusion/exclusion criteria, a total of 82 patients were identified and 72 (87.8%) presented to the hospital for follow-up. There were 39 patients with quadriceps graft (30.64 ± 8.71, range: 18-53 years) and 33 patients with hamstrings (28.60 ± 6.74, range: 18-46 years). No statistically significant difference between groups was detected with regard to KT-1000 measurements (p = 0.326). No significant difference was found between the mean postoperative Lysholm (p = 0.299), the modified Cincinnati (p = 0.665) and the general SF-36 scores between groups (p = 0.588). Less side-to-side thigh diameter difference was noted in the quadriceps graft group (p = 0.026). CONCLUSION: In conclusion, similar clinical results, in terms of stability and subjective measures, can be obtained after ACL reconstruction both with a free quadriceps and a 4-strand hamstring tendons autograft. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Double whip stitch for free graft femoral fixation in ACL reconstruction: experimental study on porcine model.

BACKGROUND AND AIMS: Using free quadriceps tendon graft for anterior cruciate ligament (ACL) reconstruction has become more popular in the last years due to the low morbidity at the harvest site and biomechanical and structural properties similar to other types of graft (hamstring and patellar tendons). As long as the tibial tunnel fixation with interference screws is considered the standard fixation, femoral fixation is still an open subject. Even though the most common type of femoral tunnel fixation are the cortical suspension devices, the type of suture used for tying the graft to the loop is still evaluated and discussed. We aimed to evaluate the resistance and elongation of a double whip stitch used for tying a tendon to the loop of a cortical suspension device. METHOD: We used 10 porcine flexor digitorum profundus as free graft for a graft-suture-cortical suspension device construct using the double whip stitch. The total length of the construct and tendon length were recorded before and after the test was performed. Tensioning curves, total construct elongation and maximum tension at breaking point were electronically recorded on the testing device's software. The mean values and coefficient of variance were assessed. RESULTS: We noted the breaking of the suture wire where the wires passed through the loop of the cortical suspension device as final point for all tests. The mean of maximum load was 505.68N (Max=639.38 N; min=358.93 N; SD=82.88078 N) and the mean of total construct elongation was 39.54784mm (Max= 48.60466 mm; min=31.74853 mm; SD=4.85371 mm). CONCLUSION: With some minor improvement in technique and graft preconditioning and pretensioning, the double whip stitch can be used in connecting a free tendon to a cortical suspension device.

Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon?

PURPOSE: We conducted this study to establish if the transition from a lateral approach (LA) to the direct anterior approach (DAA) for a low volume hip arthroplasty surgeon during the steep learning curve can be performed maintaining the muscle sparing approach of the DAA without increasing the complication rates. METHODS: In this controlled, prospective, randomized clinical study we investigated 70 patients (35 DAA, 35 LA) with similar demographics that underwent a total hip arthroplasty. Assessment of the two approaches consisted of determining the invasiveness through serum markers for muscle damage (i.e. myoglobin, creatine kinase and lactate dehydrogenase), the operative parameters such as post-operative pain and rescue medication consumption, the component positioning and complication rates. RESULTS: Post-operative myoglobin levels were higher (p < 0.001) in the LA group (326.42 ± 84.91 ng/mL) as compared to the DAA group (242.80 ± 71.03 ng/mL), but with no differences regarding other biomarkers for muscle damage. Pain levels were overall lower in the DAA group, with a statistical and clinical difference during surgery day (p < 0.001) associated with lower (p < 0.001) rescue medication consumption (median 1 (1; 3) mg morphine vs. 3 (2; 4) mg morphine). Most patients in the LA group reported chronic post-operative pain throughout all three evaluated months, while the majority of patients in the DAA group reported no pain after week six. Component positioning did not differ significantly between groups and neither did complication rates. CONCLUSION: The DAA can be transitioned from the LA safely, without higher complication rates while maintaining its muscle spearing advantages when performed by a low volume hip arthroplasty surgeon.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With a Free Quadriceps Tendon Autograft.

Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction aims to restore the 2 functional bundles of the ACL in an attempt to better reproduce the native biomechanics of the injured knee and promote long-term knee health. However, this concept is not fully accepted and is not performed on a standard basis. In addition, the superiority of this technique over the conventional single-bundle technique has been questioned, especially the long-term clinical results. One of the down sides of the double-bundle reconstruction is the complexity of the procedure, with increased risks, operative time, and costs compared with the single-bundle procedure. Also, the revision procedure, if necessary, is more challenging. We propose a technique that has some advantages over the traditional double-bundle procedure, using a single femoral tunnel, 2 tibial tunnels, and a free quadriceps tendon autograft.

Outside-In Deep Medial Collateral Ligament Release During Arthroscopic Medial Meniscus Surgery.

Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic, irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgus-extension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.

Free Bone Plug Quadriceps Tendon Harvest and Suspensory Button Attachment for Anterior Cruciate Ligament Reconstruction.

The most commonly used autografts for anterior cruciate ligament reconstruction are the bone-patellar tendon-bone and hamstring tendons. Each has its advantages and limitations. The bone-patellar tendon-bone autograft can lead to more donor-site morbidity, and the hamstring autograft can be unpredictable in size. The quadriceps tendon, with or without a bone block, has been described as an alternative graft source and has been used especially in revision cases, but in recent years, it has attracted attention even for primary cases. We report a technique for harvesting a free bone quadriceps tendon graft and attaching an extracortical button for femoral fixation for anterior cruciate ligament reconstruction.