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Background: We created a multicenter survey for Italian orthopedic surgeons on how they approach leg length discrepancy (LLD) when dealing with primary total hip arthroplasty. Aim of the study was to show how surgeons manage LLD and follow the literature recommendations during clinical practice., Methods: The survey was composed of 25 questions divided into four sections: 1-surgeon's profile, 2-preoperative and 3-intraoperative evaluation, and 4-postoperative management. In this paper, we report results to answer Sects. 1 and 2. Absolute and relative frequencies of answers to Sects. 2 and 3 are reported. We divided the participants in subgroups based on the "surgeon's profile" and evaluated difference in the answers given., Results: Absolute and relative frequencies demonstrate low agreement among participants in all phases of LLD management. We demonstrated a statistically significant difference based on the surgeon's profile regarding these questions: radiographic measure of LLD depending on working experience, p = 0.008; digital planning based on surgeons' age, p < 0.001, and workplace, p = 0.026; intraoperative anatomical landmarks based on numbers of procedures per year, p = 0.020; and use of intraoperative X-rays based on working experience, p = 0.002., Conclusions: LLD is a debated topic with no definitive recommendations. Many decisions still depend on tradition and surgeons' preference., (© 2024. The Author(s).)

Background: Tibiofemoral components rotational congruency affects the total knee arthroplasty (TKA) success. The smart insert sensor (I-S) helps to establish tibial component rotation reciprocally to a fixed femoral rotation. We aimed (1) to validate the use of I-S as a possible tool to reach reproducible reciprocal femorotibial rotation (RftR) in TKA independently from anatomic landmarks, reducing outliers in combined and mismatched femorotibial rotation (CftR and MMftR, respectively) positioning and (2) to validate the "curve-on-curve" method for a specific type of asymmetrical tibial component., Methods: From February 2018, we conducted a prospective case-control study including 106 patients undergoing TKA. Patients were divided into 2 groups based on the method used to establish tibial component rotation: with the I-S use (group A, n = 53) and with the standard "curve-on-curve" technique (group B, n = 53). Rotational alignment was calculated using the Berger protocol with postoperative computed tomography scanning. Alignment parameters measured were tibial and femoral component rotations (tR, fR), the CftR, the MMftR, and the RftR., Results: Intraoperative rotation measured by I-S correlated the best with RftR (r = 0.84; P < .001) at the post-operative CT scanning. No significant differences were found between groups A and B regarding all types of rotation (fR: P  = .774; tR: P  = .467; CftR: P  = .847) except for MMftR ( P  = .036) and RftR ( P  = .023). There were no outliers in group A but 27 and 12 outliers in group B for MMftR and CftR respectively ( P < .001; P  = .032)., Conclusions: The TKA components' rotation established using a smart I-S intraoperatively is ascribable to the RftR at postoperative computed tomography scan. The I-S helps reduce outliers in the CftR and MMftR. An asymmetrical tibial base plate implanted using the curve-on-curve technique does not create a neutral reciprocal femorotibial rotation significantly increasing the number of cases with mismatched femorotibial internal rotation., (© 2024 The Authors.)

Objectives : This study aims to evaluate the patellar height changes after distal femur (DF) endoprosthetic replacement (EPR) and its impact on anterior knee pain (AKP) and range of motion (ROM). Methods: A retrospective review of three institutions' databases was performed. The patellar height was determined using the modified Insall-Salvati ratio (MIS), the Blackburne-Peel (BP) and the Caton-Deschamps (CD) indexes. Data regarding AKP and ROM were collected. Results : A total of 199 patients were included. The mean age at presentation was 37.9 ± 23.1 years. The mean one-year follow-up MIS, BP and CD were 1.52 (sd: 0.41), 0.82 (sd: 0.33) and 0.93 (sd: 0.33). Patellar height decreased significantly compared to the pre-operative values according to all three scores ( p < 0.001). AKP was reported by 34 (17.1%) patients at 1 year follow-up. Patients with patella baja (MIS < 1.2) or pseudo patella baja (CD < 0.6) had a higher incidence of AKP ( p = 0.037 and p = 0.024, respectively). The mean flexion ROM was 91°, with a direct correlation with patellar height (MIS p = 0.020, BP p = 0.036 and CD p = 0.036). Conclusion : The restoration of the native position of the joint line in DF EPR is important to maintain optimal patellofemoral biomechanics. Despite surgeons' tendency toward a reduction in patellar height with respect to pre-operative values, an increase in patellar height might help to achieve better knee flexion and reduce AKP.

Background: In periprosthetic joint infections (PJIs), the surgeon's role becomes pivotal in addressing the infection locally, necessitating the surgical removal of infected and necrotic tissue. Opportunity to enhance the visualization of infected tissue during surgery could represent a game-changing innovation., Objective: The aim of this narrative review is to delineate the application of intraoperative fluorescence imaging for targeting infected tissues in PJIs., Methods: A systematic review, adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, was carried out. The search included multiple online database; MEDLINE, Scopus, and Web of Science. For data extraction the following were evaluated: (i) diagnosis of musculoskeletal infection; (ii) use of intraoperative fluorescence imaging; (iii) infected or necrotic tissues as target., Results: Initially, 116 studies were identified through online database searches and reference investigations. The search was narrowed down to a final list of 5 papers for in-depth analysis at the full-text level. Subsequently, 2 studies were included in the review. The study included a total of 13 patients, focusing on cases of fracture-related infections of the lower limbs., Conclusion: The primary and crucial role for orthopedic surgeons in PJIs is the surgical debridement and precise removal of necrotic and infected tissue. Technologies that enable clear and accurate visualization of the tissue to be removed can enhance the eradication of infections, thereby promoting healing. A promising avenue for the future involves the potential application of intraoperative fluorescence imaging in pursuit of this objective.

(1) Background: Chronic non-bacterial osteomyelitis (CNO), also known as sclerosing osteomyelitis of Garrè, is a rare inflammatory bone disease with a specific clinical picture, uncertain pathogenesis, and no consensus on an effective treatment. Most frequently affecting other long bones, CNO may rarely involve the clavicle. The aim of this study was to present the results of a series of patients affected by CNO of the clavicle treated with total and partial clavicula resection. In addition, a literature review of different types of treatment of CNO was performed. (2) Methods: We retrospectively reviewed three patients with Sclerosing Osteomyelitis of Garre' of the clavicle treated with partial resection of the clavicle (one) and with total clavicular resection (two). (3) Results: Patients (two female and one male) were an average age of 35.7 years at the time of the operation. At the 4-year follow-up, the mean active ROM was: 143° forward flexion, 133° abduction, 42° external rotation with an internal rotation of two patients at the interscapular level and one patient at the lumbosacral junction. The mean ASES score was 92/100 (range 87-100). In the literature review, after screening the abstracts and full texts for eligibility, 34 studies met the inclusion criteria. Conclusions: Partial or total clavicular resection resulted an effective treatment of CNO of the clavicle. The procedure seems to be particularly indicated after the failure of more conservative treatments.

Background and Objective: Proximal femoral replacement due to revision hip arthroplasty or catastrophic proximal femur fracture fixation failures with considerable proximal femur bone loss can lead to a substantial loss of function of the soft tissue around the hip and the abductor muscles in particular. Surgical techniques of gluteus medius repair and/or abductor mechanism reattachment/reconstruction are widely debated in the literature, but it is quite rarely dealt with in the context of megaprosthesis and femoral reconstruction, particularly in non-oncologic patients. The aim of this study is to present a narrative review of the literature on techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions., Methods: MEDLINE, Embase, and Cochrane databases were searched by two researchers independently from inception until February 1st, 2023 (923 for MEDLINE and 963 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date). Articles examining proximal femoral reconstruction with megaprosthesis or allograft prosthesis were included. Studies concerning cadaver and oncologic patients were excluded. If the researchers failed to find an agreement on whether to include a study, the senior researcher would make a final decision in such cases. Data were extracted and stored, and qualitative synthesis was performed., Key Content and Findings: A total of 1,157 articles from MEDLINE, 11,187 articles from Embase, and 0 articles from Cochrane were identified. Of 12,344 articles, the structured screening process revealed 10 eligible trials. Four different types of abductor musculature reconstruction/reinsertion were identified., Conclusions: Multiple and complex revision hip arthroplasties as well as multiple surgical procedures for proximal femur fracture fixations failures may have a great impact on proximal femur bone stock condition and soft tissue preservation requiring the use of a proximal femur megaprosthesis. In such cases, the abductor mechanism reconstruction and/or reattachment is achievable with different techniques that can be resumed in four different groups: direct suture to the prosthesis, trochanteric sleeve osteotomy, muscle-to-muscle suture, and synthetic tube augmentation suture., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-23-26/coif). The series “Modular Implants for Revision Arthroplasty in Orthopedics” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2024 Annals of Joint. All rights reserved.)

Introduction: Total hip arthroplasty (THA) performed for femoral neck fractures (FNFs) is becoming a more frequent treatment in the active elderly population. Since there is limited research available presenting clinical outcomes after THA using the anterior-based muscle sparing (ABMS) approach, the aim of this study was to compare this surgical approach to the direct lateral (DL) approach in patients treated by THA for FNFs., Materials and Methods: We retrospectively reviewed the data prospectively collected as a part of our "Hip Fracture Unit" and included 163 patients who underwent THA from January 2016 to January 2019 for acute displaced FNFs., Results: A total of 132 patients who completed a minimum 2-years follow up (69 in the ABMS group and 63 in DL group) were included. The ABMS group demonstrated significantly shorter time to reach milestone for hospital discharge (1.5 Days vs 2.1 days, P = .018), while no statistically significant differences were detected in peri-operative complications. At 3 months, the timed up and go test, the Harris Hip Score (HHS) and the Oxford ip Score (OHS) were significantly better ( P = .024, .032 and .034, respectively) in the ABMS group compared to the DL group. No differences were found in functional outcomes (HHS and OHS) nor in complication rate at 6, 12 and 24 months., Discussion: This is one of the first studies to analyze functional results of THA performed for FNFs through an ABMS approach. Results are in line with those already present in the Literature., Conclusion: ABMS approach allows earlier mobilization and better early functional outcomes, compared to DL approach, in patients undergoing THA for acute displaced FNF. No differences are found after 6 months in functional results and complications rate., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Knee varus alignment represents a notorious cause of knee osteoarthritis. It can be caused by tibial deformity, combined tibial-femoral deformity and/or ligament imbalance. Understanding malalignment is crucial in total knee arthroplasty to restore frontal plane neutral mechanical axis. The aim of this study was to determine which factor contributes the most to varus osteoarthritic knee and its related surgical implications in performing a total knee arthroplasty., Methods: We retrospectively evaluated 140 patients operated for total knee arthroplasty due to a varus knee. Full-leg hip to ankle preoperative X-rays were taken. Radiological parameters recorded were: mechanical axis deviation, hip-knee-ankle, anatomical-mechanical angle, medial neck shaft angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), lateral proximal femoral angle, lateral distal tibial angle (LDTA), femoral bowing, and length of tibia and femur. We also determined ideals tibial and femoral cuts in mm according to mechanical alignment technique. A R2 was calculated based on the linear regression between the predicted values and the observed data., Results: The greatest contributor to arthritic varus (R = 0.444) was MPTA. Minor contributors were mLDFA (R = 0.076), JLCA (R = 0.1554), LDTA (R = 0.065), and femoral bowing (R = 0.049). We recorded an average of 7.6 mm in lateral tibial cut thickness to restore neutral alignment., Conclusions: The radiological major contributor to osteoarthritic varus knee alignment is related to proximal tibia deformity. As a surgical consequence, during performing total knee arthroplasty, the majority of the correction should therefore be made on tibial cut., (© 2022. The Author(s).)