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Purpose: Different kinds of bone preserving hip stems have been created to assure a more physiological distribution of the strengths on the femur. The aim of this research is to evaluate the density reaction of the periprosthetic bone while changing the conformation of the prosthetic implant on dual-energy X-ray - absorptiometry (DXA)., Methods: This is a prospective, single-centre study assessing bone remodelling changes after implantation of two short hip stems, dividing the patients in two groups according to the implant used: 20 in group A, Metha (B-Braun), and 16 in group B, SMF (Smith and Nephew). All participants had a pre-operative and a post-operative (24 months) DXA evaluating the changes in bone mass density (BMD) occurred in the five Gruen's zones., Results: Compared to the pre-operative value, differences in BMD percentage were statistically significant only in ROI 4 (p < 0.05), with an increase in both groups (9 and 18%, respectively). The average increase in BMD was of 7.3% and 7.2% in the 2 groups., Conclusion: According to our study, both stems have proved able to provide good load distribution across the metaphyseal region favouring proper system integration. Nonetheless, is certainly needed to perform other studies with longer follow-up and bigger populations to give strength to these conclusions.

Introduction: In the last three decades, total hip replacement in young patient became a habitual procedure. Principles of bone preservation are pushing many surgeons to implant conservative femoral components in patient younger than 65 years. Despite an overall good survivorship and clinical outcomes of conservative implants, failed cases are reported and the need to revise a conservative femoral component became an occasional procedure (with high prevalence of failed resurfacing implants)., Methods: During conservative femoral component revisions, we analyzed proximal bone stock preservation, considering the type of original component removed, etiology of failure, timing of revision, and femoral explantation technique., Results: We identified four patterns of proximal femoral changes (types I-IV). We suggest, for each of them, a revision strategy directed toward a "conservative revision procedure" using conservative or primary component. Out of our 21 cases, none underwent further revision due to mechanical failure (follow-up ranging from 6 to 152 months, mean 54 months). We had two case of re-operation: one for early septic loosening and one for prosthetic modular neck fracture., Conclusions: If literature offers well-established guidelines to femoral revision of conventional stems, there is, on the other hand, a lack of data about revision strategies in presence of failed conservative implants. Although the mean follow-up of our procedures is still too short (4.5 years) to give final conclusions, we would leave a message: a conservative hip arthroplasty is not a "one-time" opportunity for young and active people. A "conservative revision" is a valid option for at least a part of them, when an early failure of primary procedure occurred.

Introduction: Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications., Methods: 76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years)., Results: Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed., Discussion and Conclusions: Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: The aim of this study is to evaluate the incidence of infections in MoM total hip replacement revisions and to propose a therapeutic algorithm that can reduce the onset of this complication. Total hip arthroplasty is one of the most successful procedures performed annually in the world. As the population ages, the number of primary arthroplasty procedures performed each year is rising in conjunction with an increasing revision burden. Metal on Metal (MoM) total hip arthroplasties were reintroduced in over the last fifteen years to meet these needs, larger diameters, improved lubrication, better stability, increased ROM and wear properties of the bearing couple. These advantageous features have led to an exponential diffusion of MoM. Since over last decade, it has become evident that hip replacements with MoM bearing have significantly higher revision rates compared to those with Metal on Polyethylene. The common pathway for this failure mode appears to be increased wear or corrosion with excessive release of metal ions and nanoparticles. Complications such as elevated serum metal ion levels, aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) and pseudotumours have all been well documented, but recent studies suggest increased risk of infection with MoM bearing surfaces., Patients and Methods: We collect data from a cohort of 44 patients who underwent revision of total hip arthroplasty between 2014 and 2017 for the complication of MoM bearing. Studied by radiological images, blood tests, and intraoperative clinical status, part of the population was treated with one stage revision, while the other was treated with a two-stage revision., Results: Results showed a difference in the occurrence of infections in the two populations., Conclusions: We consider it appropriate to perform two-stage revision in all case of failure of MoM replacement so as to allow to minimize the likelihood of infection in patients with damaged tissues by ALVAL, pseudotumour, and necrosis that could create an ideal environment for bacterial development.

Introduction: In last three decades, total hip replacement in young patients became an habitual procedure. Principles of bone preservation are pushing many surgeons to implant conservative femoral components in patient younger than 65 years. Despite an overall good survivorship and clinical outcomes of conservative implants, failed cases are reported and the need to revise a conservative femoral component became an occasional procedure (with high prevalence of failed resurfacing implants)., Methods: During conservative femoral component revisions, we analyzed proximal bone stock preservation, considering the type of original component removed, aetiology of failure, timing of revision, and femoral explantation technique., Results: We identified four patterns of proximal femoral changes (types I-IV). We suggest, for each of them, a revision strategy directed toward a "conservative revision procedure" using conservative or primary component. Out of our 21 cases, none underwent further revision due to mechanical failure (follow-up ranging from 6 to 152 months, mean 54 months). We had two cases of re-operation: one for early septic loosening and one for prosthetic modular neck fracture., Conclusions: If literature offers well-established guidelines to femoral revision of conventional stems, there is, on the other hand, a lack of data about revision strategies in presence of failed conservative implants. Although the mean follow-up of our procedures is still too short (4.5 years) to give final conclusions, we would leave a message: a conservative hip arthroplasty is not a "one time" opportunity for young and active people. A "conservative revision" is a valid option for at least a part of them, when an early failure of primary procedure occurred.

Hip dislocation is a major and common complication of total hip arthroplasty (THA), which appears with an incidence between 0.3% and 10% in primary total hip arthroplasties and up to 28% in revision THA. The hip dislocations can be classified into three groups: early, intermediate and late. Approximately two-thirds of cases can be treated successfully with a non-operative approach. The rest require further surgical intervention. The prerequisite to developing an appropriate treatment strategy is a thorough evaluation to identify the causes of the dislocation. In addition, many factors that contribute to THA dislocation are related to the surgical technique, mainly including component orientation, femoral head diameter, restoration of femoral offset and leg length, cam impingement and condition of the soft tissues. The diagnosis of a dislocated hip is relatively easy because the clinical situation is very typical. Having identified a dislocated hip, the first step is to perform a closed reduction of the implant. After reduction you must perform a computed tomography scan to evaluate the surgical options for treatment of recurrent dislocation that include: revision arthroplasty, modular components exchange, dual-mobility cups, large femoral heads, constrained cups, elimination of impingement and soft tissue procedures. The objective is to avoid further dislocation, a devastating event which is increasing the number of operations on the hip. To obtain this goal is useful to follow an algorithm of treatment, but the best treatment remains prevention.

Radial head excision has always been a safe commonly used surgical procedure with a satisfactory clinical outcome for isolated comminuted radial head fractures. However, diagnosis of elbow instability is still very challenging and often underestimated in routine orthopaedic evaluation. We present the case of a 21-years old female treated with excision after radial head fracture, resulting in elbow instability. The patient underwent revision surgery after four weeks. We believe that ligament reconstruction without radial head substitution is a safe alternative choice for Mason III radial head fractures accompanied by complex ligament lesions., (Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.)

Purpose: The aim of this multicentric study was to evaluate results of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and number of complications., Methods: A consecutive series of 76 patients with proximal humeral fractures were treated with locking plate using a minimally invasive antero-lateral approach in two orthopaedic departments. Functional results with Constant score and radiographic evaluation were available for 74 patients at one-year follow up., Results: The patients achieved a mean Constant score of 71 (range 28-100). Each functional result was evaluated also for both centres without significant differences. Significant statistical differences were only found for younger patients with better results (p < 0.05). Twenty patients (27%) developed complications. Subacromial impingement occurred in 16.2% of cases for varus malreduction (6.7%) and for too proximal plate positioning (9.5%). Primary screws perforation (2.7%), secondary perforation due to cut-out (1.4%), avascular necrosis (AVN) of humeral head (1.4%), partial resorption of greater tuberosity (2.7%), secondary dislocation of the greater tuberosity (2.7%) and stiffness (2.7%) were the other complications observed., Conclusions: The MIPO technique for proximal humeral fractures was safe and reproducible for most common patterns of fracture. Major complication rate was apparently low due to a soft tissue sparing, deltoid muscle and circumflex vessels, with easy access of the bar area to correct positioning of the plate.

Purpose: Bone stock reconstruction in TKR surgery is one of the biggest challenges for the surgeon. According to some, authors causes of bone stock loosening are multiple, including stress shielding, osteolysis from wear, septic or aseptic loosening, and bone loss caused by a poorly balanced implant. Moreover, bone loss may be iatrogenic at the time of implant removal, indicating that bone preservation during implant removal is critical., Methods: Defect localization and extension affect the surgeon's decisions about the choice of the surgical technique and the type of plant to be taken. Today there are several options available for bone deficiency treatment. The treatment choice is undoubtedly linked to the cause of revision, experience and personal philosophy, but it is necessary to consider also the patient's age, expectations of life, functional requirements and bone quality. Many authors prefer bone stock reconstruction techniques in patients with high bone quality and a better quality of life with more prospects. In patients with lower lease on life and lower bone quality the best bone replacement techniques are of modular systems, wedges, and augments. In cases with septic bone loss, more or less extended, different authors recommend reducing bone grafts in favor of modular prostheses to reduce the risk of graft contamination., Results: All of these techniques have been shown to be durable in midterm outcomes, but concerns exist for a number of reasons, including disease transmission, resorption, fracture, immune reaction to allograft, the cost of custom prostheses, the inability to modify the construct intraoperatively and the overall technical challenge of applying these techniques., Conclusions: The choice between different surgical options depends on bone defect dimension and characteristics but are also patient-related. Reestablishment of well-aligned and stable implants is necessary for successful reconstruction, but this can't be accomplished without a sufficient restoration of an eventual bone loss.

Purpose: Several studies have investigated effectiveness of fibrin spray or bipolar sealer to control peri-operative bleeding and reduce the need for blood transfusion, but a direct comparison between the two methods has not been previously performed. We conducted a prospective randomised trial, with standard electrocautery as a control group., Methods: In our investigation, 95 patients were randomised to one of three parallel groups receiving (1) 10 mL of topical fibrin spray before closure, (2) haemostasis with radiofrequency energy using a bipolar sealer, and (3) standard electrocautery. All patients and staff apart from the surgeons were blinded until data analysis was complete. Peri-operative blood loss has been calculated using a formula described by Ward and Gross (considering estimated patient blood volume, pre- and post-operative haemoglobin and haematocrit levels), with mention of eventual blood re-infusion or transfusion, at given intervals from surgery (6, 24, 48, 72 hours)., Results: Mean blood loss was lower for both methods investigated, compared to the control group at every time interval considered, although differences were stronger for fibrin spray [Quixil]. Mean blood saving at the given intervals from surgery (6-24-48-72 hours) was respectively 96 ml, 129 ml, 296 ml, and 121 ml for bipolar sealer [Aquamantys] and 235 ml, 368 ml, 642 ml, and 490 ml for fibrin spray. These results are statistically significant (p = 0.05) for fibrin spray at every interval compared to control values, while a significance is detectable for bipolar sealer only at 48 hours after surgery., Conclusions: The fibrin spray group had the best performance in terms of blood loss, significantly reduced in comparison with the control group and bipolar sealer group. Blood loss reduction for the bipolar sealer was remarkable only at 48 hours, compared with the control group. Blood loss reduction for fibrin spray was significant at every time interval considered. Differences between the two treatments investigated and the control group narrowed slightly at 72 hours, as an expression of spontaneous homeostasis. Notable is the fact that blood volume saved with fibrin spray at 24 and 48 hours is comparable to the volume of at least one blood unit. A cost-effectiveness analysis should be considered in term of expense, biological risks (related to blood transfusion or human-derived products use) and bleeding-related complications.

Background: The renewed popularity of resurfacing hip arthroplasty in the last 10 years has generated a remarkable quantity of scientific contributions based on mid- and short-term follow-up. More than one paper has reported a consistent early revision rate as a consequence of biological or biomechanical failure. Two major complications are commonly described with resurfacing implants: avascular necrosis and femoral-neck fracture. A close relationship between these two events has been suggested, but not firmly demonstrated, whereas cementing technique seems to be better understood as potential cause of failure., Methods: We performed an in vitro study in which four different resurfacing implants were evaluated with a simulated femoral head, two types of cement, (low and high viscosity) and two cementing techniques: direct (cement apposition directly on the femoral head) and indirect (cement poured into the femoral component)., Results: High-viscosity cement showed homogeneous distribution over the entire femoral head. Low-viscosity cement showed a massive polar concentration with insufficient, if not absent, distribution in the equatorial zone., Conclusion: Polar cement concentration could be a risk factor for early implant failure due to two effects on the femoral head: biological (excessive local exothermic reaction could cause osteocyte necrosis) and biomechanical (which could lead to uneven load distribution on the femoral head).

In this in vitro study, 4 different resurfacing implants have been evaluated with a simulated femoral head: 2 types of cement have been used (low and high viscosity) and 2 different cementing techniques have been performed: direct (cement apposition directly on the femoral head) and indirect (cement poured into the femoral component). High-viscosity cement shows a homogeneous distribution all over the femoral head. Low-viscosity cement shows a massive polar concentration with insufficient if not absent distribution in the equatorial zone. Polar cement concentration could be held as a risk factor for early implant failure. It could have 2 effects on femoral head: biologic (excessive local exothermic reaction could cause necrosis of the osteocytes) and biomechanical (it could lead to uneven load distribution on the femoral head)., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Resurfacing replacement represents the most conservative solution available for total arthroplasty of the hip. However, despite the excellent results reported by highly experienced surgeons, a small but not insignificant body of literature has been published on the more controversial aspects of this approach, mainly those related to the biological and mechanical vulnerability of the retained epiphysis. We report here our evaluation of most of the variables inherent to this procedure (surgical exposure, implant design, technical steps). Based on our results, we conclude that the short-term outcome is strongly related to the surgical approach and the relationship between implant design and cementing technique. Even if posterior approaches are currently widely accepted for resurfacing replacement, the ability to preserve the medial circumflex artery has been questioned, and an alternative exposure has been proposed with good results (antero-lateral, lateral and digastric trochanteric osteotomy). Moreover, a minimally invasive posterior approach could increase the risks of vascular damage. Alternatively, inner implant geometry could affect the distribution of cement over the epiphysis when other variables (direct or indirect cementing technique, viscosity) are not properly selected.

Total hip replacement is showing, during the last decades, a progressive evolution toward principles of reduced bone and soft tissue aggression. These principles have become the basis of a new philosophy, tissue sparing surgery. Regarding hip implants, new conservative components have been proposed and developed as an alternative to conventional stems. Technical and biomechanical characteristics of metaphyseal bone-stock-preserving stems are analyzed on the basis of the available literature and our personal experience. Mayo, Nanos and Metha stems represent, under certain aspects, a design evolution starting from shared concepts: reduced femoral violation, non-anatomic geometry, proximal calcar loading and lateral alignment. However, consistent differences are level of neck preservation, cross-sectional geometry and surface finishing. The Mayo component is the most time-tested component and, in our hands, it showed an excellent survivorship at the mid-term follow-up, with an extremely reduced incidence of aseptic loosening (partially reduced by the association with last generation acetabular couplings). For 160 implants followed for a mean of 4.7 years, survivorship was 97.5% with 4 failed implants: one fracture with unstable stem, 1 septic loosening and 2 aseptic mobilizations. DEXA analysis, performed on 15 cases, showed a good calcar loading and stimulation, but there was significant lateral load transfer to R3-R4 zones, giving to the distal part of the stem a function not simply limited to alignment. Metaphyseal conservative stems demonstrated a wide applicability with an essential surgical technique. Moreover, they offer the options of a "conservative revision" with a conventional primary component in case of failure and a "conservative revision" for failed resurfacing implants.

The renewed popularity of resurfacing hip arthroplasty (RHA) in the last five years has generated a remarkable quantity of scientific contributions based on mid- and short-term follow-up. In spite of some large series with extremely low complication rates, more than one paper has reported a consistent early revision rate as a consequence of biological or biomechanical failure. Two major complications are commonly described with resurfacing implants: avascular necrosis and neck fracture. A close relationship between these two events has been suggested, but not firmly demonstrated, while surgical exposure and implant positioning seem to be better understood as potential causes of failure. However, it may happen that neither avascular necrosis nor neck fracture can be clearly recognised in a failed resurfacing implant: it is what we have directly experienced, with a missed fracture at the head-neck junction, evolved in non-union, beneath the dome of the femoral component. The present report, besides a brief clinical history, tries to give a possible interpretation of such an unusual complication.