Dislocation of primary total hip arthroplasty: Analysis of risk factors and preventive options.

Total hip arthroplasty (THA) is one of the most successful elective operations in orthopedic surgery for improving pain and functional disability in patients with end-stage joint disease. However, dislocation continues to be a troublesome complication after THA, as it is a leading cause of revision and is associated with substantial social, health, and economic costs. It is a relatively rare, usually early occurrence that depends on both the patients' characteristics and the surgical aspects. The most recent and important finding is the special attention to be given preoperatively to spinopelvic mobility, which is closely related to the incidence of dislocation. Consequently, clinical and radiographic assessment of the lumbar spine is mandatory to identify an altered pelvic tilt that could suggest a different positioning of the cup. Lumbar spinal fusion is currently considered a risk factor for dislocation and revision regardless of whether it is performed prior to or after THA. Surgical options for its treatment and prevention include the use of prostheses with large diameter of femoral head size, dual mobility constructs, constrained liners, and modular neck stems.

Diagnosis of periprosthetic hip infection: a clinical update.

Periprosthetic joint infection (PJI) is a serious complication following hip arthroplasty, which is associated with significant health cost, morbidity and mortality. There is currently no consensus in the optimal definition of PJI, and establishing diagnosis is challenging because of conflicting guidelines, numerous tests, and limited evidence, with no single test providing a sensitivity and specificity of 100%. Consequently, the diagnosis of PJI is based on a combination of clinical data, laboratory results from peripheral blood and synovial fluid, microbiological culture, histological evaluation of periprosthetic tissue, radiological investigations, and intraoperative findings. Usually, a sinus tract communicating with the prosthesis and two positive cultures for the same pathogen were regarded as major criteria for the diagnosis, but, in recent years, the availability of new serum and synovial biomarkers as well as molecular methods have shown encouraging results. Culture-negative PJI occurs in 5-12% of cases and is caused by low-grade infection as well as by previous or concomitant antibiotic therapy. Unfortunately, delay in diagnosis of PJI is associated with poorer outcomes. In this article, the current knowledge in epidemiology, pathogenesis, classification, and diagnosis of prosthetic hip infections is reviewed.

Cemented and uncemented stems for displaced femoral neck fracture in the elderly. Retrospective study with a minimum 1-year follow-up.

BACKGROUND AND AIM: Displaced femoral neck fracture (FNF) is a common and significant health issue especially in older population because of the high rates of mortality and complications. The standard surgical treatment is total or partial hip replacement, including a cemented or uncemented stem. The cemented prosthesis is considered the safer option because of a lower rate of periprosthetic fractures (PPFs) as well as an actually reduced risk of bone cement implantation syndrome (BCIS). This retrospective study aims to assess the efficacy and safety of cemented versus uncemented femoral stem for FNF in patients ≥70 years. METHODS: 139 patients affected by displaced FNF underwent hip replacement, receiving 89 cemented (64%) and 50 uncemented (36%) stems. Inclusion criteria were: ≥70 years of age, an ICD-9-CM diagnose code 820.00, 820.01, 820.02, 820.03, 820.10, 820.8, and a minimum 1-year follow-up. A p value <0.05 was considered statistically significant. RESULTS: Surgical time, overall perioperative complication rate with a particular focus on the thromboembolic events, and PPFs incidence were evaluated comparing cemented and uncemented group. No difference in duration of surgery was found. Intraoperative complications were not detected. Pulmonary embolism and deep vein thrombosis were observed each in 1 case of cemented prosthesis. Periprosthetic femoral fractures occurred only in the uncemented group postoperatively, with a statistically significant difference (p<0.05). CONCLUSIONS: The low incidence of BCIS and the higher risk of postoperative PPFs in cemented and uncemented stems, respectively, suggest that the use of cementation is a safer procedure.

Late intraprosthetic dislocation of a monoblock dual-mobility cup cemented into a well-fixed cementless acetabular shell. A case report.

Intraprosthetic dislocation (IPD) is a specific implant-related complication of dual mobility (DM) implants, which is defined as a dissociation of polyethylene (PE) liner from the femoral head. We report a unique case of  late IPD of a monoblock DM cup cemented into a well-fixed cementless acetabular shell for recurrent dislocation of total hip arthroplasty (THA). A 77-year-old woman was admitted to our department for acute right hip pain, functional impairment and inability to bear weight without any trauma. Three years earlier, she underwent revision THA for recurrent dislocation with a monoblock DM cup cemented into a well-fixed cementless acetabular shell according to the "double-socket" technique. Three months after that revision the patient experienced an anterior THA dislocation, which was managed by closed reduction under sedation in the emergency room. No additional episodes of prosthesis instability occurred. Upon admission, radiographic evaluation showed  right THA dislocation. X-rays performed  after closed reduction revealed eccentric positioning of the head inside the cup, and a direct contact between the metal head and the cup was revealed by subsequent CT scan, confirming the suspicion of IPD. The patient underwent revision surgery, during which the PE liner was found lodged within the cup in a subluxated position, disassembled from the inner head. Both the acetabular cup and modular femoral stem proved well-fixed and impossible to remove, therefore they were retained. The explanted DM components were replaced with new ones of the same size and, thanks to the femoral neck's modular nature, it was substituted with a longer one, which resulted in improved stability against intraoperative stress maneuvers. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a good functional recovery.

Fourth generation head fracture in ceramic-on-polyethylene bearing after hip revision surgery: a case report.

Fourth generation ceramic bearings (BIOLOX delta, CeramTec AG; Phlochingen, Germany) were developed to reduce wear debris and improve fracture resistance. A case of a fourth generation head fracture in ceramic-on-polyethylene (COP) coupling after hip revision surgery is reported. A 58-year-old man was admitted to our department for increasing hip pain following a direct trauma which occurred during skiing activity 4 months before. Six years earlier, he had undergone a right cementless revision surgery with a 36-mm BIOLOX delta femoral head on polyethylene liner for metallosis and foreign body reaction after primary total hip replacement for hip osteoarthritis. At admission, radiological evaluation revealed a fracture of ceramic femoral head requiring a new revision surgery. Extensive synovectomy, lavage and capsulectomy were performed. Both acetabular cup and femoral stem were well fixed with no damage of trunnion, and therefore they were retained. A 36-mm internal diameter polyethylene acetabular liner was inserted along a 36-mm BIOLOX delta head with a BioBall adapter XL. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a complete functional recovery. To our knowledge, BIOLOX delta ceramic femoral head fracture after COP hip revision surgery has not been previously reported.

Post-traumatic cystic lesion following radius fracture: a case report and literature review.

BACKGROUND: Post-traumatic osseous cystic lesions represent a rare complication in children. Usually a post-fracture cyst is a lipid inclusion cyst, which is radiolucent and may be seen adjacent to a healing torus fracture. It is typically asymptomatic and appears just proximal to the fracture line within the area of subperiosteal new bone formation. CASE REPORT: We report a case of post-fracture cyst of the distal radius in an 8 year-old girl with spontaneous resolution. A fat-fluid level within the subperiosteal cystic lesion in MRI is a typical feature of post-traumatic cystic lesion in children. DISCUSSION AND CONCLUSION: MRI or CT scan is sufficient to confirm the diagnosis of post-traumatic cystic lesions without the need for further management other than reassurance and advise that they may occasionally cause discomfort but resolve with time.

Open patellar tendon avulsion from tibial tuberosity after ACL reconstruction successfully treated with suture anchors.

Patellar tendon rupture after anterior cruciate ligament (ACL) reconstruction is a rare complication which usually occurs in the early postoperative period during rehabilitation. The management of open avulsions from tibial tuberosity has not been clearly defined yet. We describe a previously unreported case of traumatic and open patellar tendon avulsion from tibial tuberosity one year following ACL reconstruction in an elite football player which was successfully treated with suture anchors.

Late fracture of an old-generation modular neck in a titanium alloy femoral stem of a cementless total hip arthroplasty.

Neck-stem modularity gained recent popularity in hip arthroplasty for clinical advantages, and few complications have been reported. We describe an unusual two-stage failure of the bimodular neck of a cementless forged titanium alloy stem implanted 12 years before. The retrieved neck was forwarded to the manufacturer for metallurgic evaluation and failure analysis. Lengthening and bending of the superolateral aspect of the neck and double depression of the medial part prove that the prosthetic neck underwent a medial displacement and a varus rotation. The crack initiated from the superolateral corner of the fracture section, and the neck probably underwent two subsequent unstable configurations. The first horizontal part of the fracture occurred in the external surface as a result of physiological load carried on abnormal conditions of frictions. Due to increased oscillations, the end of the fracture section knocked against the inner aspect of the proximal hole of the stem, preventing further valgus displacement of the neck, which was moved forward. Consequently, the neck achieved a second unstable configuration, and the fracture propagated in the weaker direction creating a bent track. Finally, the neck broke unexpectedly as a result of the traumatic event. An incorrect placement into the femoral component during surgery was the initiation of the failure of the bimodular neck. The transitory but repeated interface motion between the neck and the stem induced a local surface irregularity acting as a starting point for crack propagation of fatigue fracture. Final failure followed a direct trauma.

Perioperative intravenous tranexamic acid reduces blood transfusion in primary cementless total hip arthroplasty.

BACKGROUND AND AIM OF THE WORK: Blood loss and transfusion requirements are common in total hip arthroplasty. Tranexamic acid is one of the most interesting options to reduce the need for blood transfusions in a variety of surgical settings. The aim of this study was to assess the efficacy of perioperative intravenous traxexamic acid regarding blood transfusion rate and volume of transfused blood without increasing adverse events after primary elective cementless total hip arthroplasty. METHODS: A comparative retrospective study was conducted in 86 healthy patients who had undergone primary cementless total hip artrhoplasty for severe joint diseases at a single institution. All surgical procedures were performed through an anterolateral Watson- Jones approach with the patient in supine position. Forty patients (TXA group) received tranexamic acid 1g as an intravenous bolus 10 minutes before skin incision and a further 1 g, diluted in 250 mL of saline solution, in continuous perfusion at 30 mL/h, following commencement of the surgery. Forty-six patients (control group) did not receive TXA. Outcome measures included BT rate, volume of transfused blood, deep vein thrombosis and occurrence of pulmonary embolism. RESULTS: BT rate was significantly less for the TXA group (37.5%) compared with the control group (65%; p=0.011). The mean blood volume transfused was also significantly less for the TXA group (240 mL) compared with the control group (450mL; p=0.009). No adverse events occurred in any group. Conclusons: Perioperative intravenous tranexamic acid is effective in reducing blood transfusion rate and volume of transfused blood, without increasing the risk of thromboembolic events in patients undergoing primary cementless total hip arthroplasty.

Higher blood loss and transfusion requirement in surface arthroplasty versus conventional total hip replacement.

BACKGROUND AND AIM OF THE WORK: Surface replacement arthroplasty (SRA) is an alternative to stemmed total hip arthroplasty (THA) providing a femoral bone preserving procedure. Because of the wider surgical dissection, an increased blood loss could be expected. This retrospective study evaluates the transfusion requirement in two homogeneous groups of patients who underwent primary hip replacement electively. METHODS: Perioperative haematological data of 42 hip resurfacing procedures and 41 conventional cementless THAs were compared. The pre- and post-operative haemoglobin (Hb) levels and the amount of blood transfusions were registered. The median values were compared with use of the non-parametric Wilcoxon signedrank test. RESULTS: In the SRA group, a significantly increased (p<0.02) preoperative Hb concentration (13.1 g/dL, range 10.9 to 15.6) was detected in comparison with the THA group (12.5 g/dL, range 10.4 to 15.2). In the resurfacing procedures a median of 900 mL (range 600 to 1500) were transfused vs. 600 (range 300 to 1500) in the conventional THAs, demonstrating a significantly higher transfusion requirement (p<0.04). CONCLUSIONS: Whereas hip resurfacing is a femoral bone preserving alternative to conventional THA with comparable clinical and radiographic outcomes, higher blood loss and transfusion requirement may occur.

Two-stage management of a spontaneous fracture of the greater trochanter through osteolytic lesions induced by polyethylene wear of a total hip arthroplasty. A case report.

Pelvic osteolysis induced by particulate debris derived from bearing surfaces is a well-known complication following total hip arthroplasty (THA). Atraumatic fractures of the greater trochanter (GT) associated with osteolytic lesions have been occasionally described. We present a case of a 71-year-old male patient who sustained an undisplaced fracture of the GT nine years following cementless metal-on-polyethylene THA. The fracture occurred through a 2.5-cm large osteolytic area, and no hip trauma was recorded. Conventional radiographs revealed peculiar signs of massive wear of the polyethylene acetabular liner (marked eccentricity of the prosthetic head and extensive osteolysis around the iliac screws), allowing to immediately conclude about the benign nature of the pathological fracture. To our knowledge, a two-stage management, planning conservative healing of the fracture and subsequent surgical replacement of the worn acetabular liner, has never been previously detailed.

Descending genicular artery injury following transient lateral patellar dislocation.

Transient lateral patellar dislocation (TLPD) is a common lesion in young adults. Vascular injury as a complication of TLPD has not been previously described. We report a case of descending genicular artery (DGA) injury after TLPD. Immediate angiography demonstrated rupture of DGA. Embolization was performed with sudden interruption of bleeding. DGA injury should be considered as a complication after TLPD and prompt diagnosis and intervention are required. We propose selective embolization as a safe and effective procedure to stop bleeding.

CT-guided radiofrequency ablation of osteoid osteoma using a multi-tined expandable electrode system.

BACKGROUND AND AIM OF THE WORK: Radiofrequency ablation (RFA) is the gold standard for the treatment of symptomatic osteoid osteoma (OO) as RFA yields both a high success and low complication rate. It has been widely utilized over the years, but recurrences of OO after this treatment have been documented. These recurrences may be the result of various factors, including incomplete tumor ablation, and are significantly higher in lesions greater than 10 mm. Thus, the need to induce thermal ablation in a wider area led us to use a Multi-Tined Expandable Electrode System (MTEES). In this study we examined the efficacy and safety of RFA using a MTEES in symptomatic OO. METHODS: Between January 2005 and June 2007, 16 patients with symptomatic OO were treated by CT-guided percutaneous RFA using a MTEES. The diameter of OO ranged from 6 to 15 mm (mean 10±2.6 mm). Patients were evaluated for clinical outcomes, complications and recurrence. Pain evaluation was assessed preoperatively, 2 weeks postoperatively and at last follow-up. RESULTS: Clinical follow-up was available for all patients at a mean of 84.3 months (range 73-96 months). Mean preoperative VAS score was 7.4 (range 5-9), two weeks after the procedure mean VAS score was 0.3 (range 0-1) with a mean change of -7.06 points (p<0.0001). At the last follow-up a complete relief from pain has been observed in all patients. No major and minor complications were observed nor recurrences. CONCLUSIONS: RFA using a MTEES has been effective, safe and reliable for the treatment of OOs. This system, by increasing the size of the necrosis, could be a viable alternative to the single needle electrode in lesions larger than 10 mm, reducing the risk of recurrence.

Rotational osteoplasty and bioabsorbable polylactate pin fixation in Pipkin type 2 fracture with acute osteochondral defect: a case report.

Pipkin fractures are relative rare high-energy lesions characterized by an intra-articular fracture of the femoral head after posterior hip dislocation. Early anatomic reduction and stable fixation are the main goals of treatment. This case evaluates the outcome of managing Pipkin type 2 fracture with acute osteochondral defect of the femoral head using "rotational osteoplasty" and bioabsorbable polylactate pin fixation. 24-year-old male patient was involved in a motorcycle accident, suffering from a left hip fracture-dislocation, and pelvic Computed Tomography revealed a Pipkin type 2 lesion. An open urgent treatment was performed. After  anatomic reduction of the femoral head fragment a large osteochondral defect in the anterior-superior weight bearing surface was evident. The pattern of the fracture allowed us to perform a "rotational osteoplasty" including rotation of the femoral head fragment, to obtain an osteochondral cartilage congruence of the anterior-superior surface. Stable fixation was obtained by three bioabsorbable polylactate pins. At four-year follow up the patient had an excellent outcome and Magnetic Resonance Imaging (MRI) showed fracture healing, minimal signs of arthritis, excluding osteonecrosis of the femoral head. The reported case confirms that Pipkin fractures are very insidious surgical urgencies. In selected cases, "rotational osteoplasty" may be an alternative to osteochondral transplant for acute osteochondral defect of the femoral head. Bioabsorbable polylactate pin fixation allowed us to have a stable fixation evaluating the bone healing process and vitality of femoral head by MRI.

Serious delayed hair toe tourniquet syndrome with bone erosion and flexor tendon lesion.

Hair toe tourniquet syndrome (HTTS) is an uncommon pediatric condition occurring when the toe is circumferentially strangulated by human hair or fibers. An 8-week-old little girl was admitted to the Emergency Department because of the worsening swelling in the right second and third toes, which had been been previously treated with a local antibiotic thinking of an infection. An unrecognized HTTS was leading the third toe to necrosis. An urgent release of the constricting band on the two toes was performed and bone erosion and partial flexor tendon lesion on the third toe were detected. We would like to raise awareness in the community and in colleagues about HTTS in children, because early recognition and urgent treatment are mandatory to provide an adequate management and prevent severe complications.

Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain.

Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described. Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma. Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with "benign" osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications.

Acetabular reconstruction with the Burch-Schneider antiprotrusio cage and bulk allografts: minimum 10-year follow-up results.

Reconstruction of severe pelvic bone loss is a challenging problem in hip revision surgery. Between January 1992 and December 2000, 97 hips with periprosthetic osteolysis underwent acetabular revision using bulk allografts and the Burch-Schneider antiprotrusio cage (APC). Twenty-nine patients (32 implants) died for unrelated causes without additional surgery. Sixty-five hips were available for clinical and radiographic assessment at an average follow-up of 14.6 years (range, 10.0 to 18.9 years). There were 16 male and 49 female patients, aged from 29 to 83 (median, 60 years), with Paprosky IIIA (27 cases) and IIIB (38 cases) acetabular bone defects. Nine cages required rerevision because of infection (3), aseptic loosening (5), and flange breakage (1). The average Harris hip score improved from 33.1 points preoperatively to 75.6 points at follow-up (P < 0.001). Radiographically, graft incorporation and cage stability were detected in 48 and 52 hips, respectively. The cumulative survival rates at 18.9 years with removal for any reason or X-ray migration of the cage and aseptic or radiographic loosening as the end points were 80.0% and 84.6%, respectively. The use of the Burch-Schneider APC and massive allografts is an effective technique for the reconstructive treatment of extensive acetabular bone loss with long-lasting survival.