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Purpose: This study aimed to formulate evidence-based recommendations for optimising wound management in hip and knee arthroplasty by exploring alternative methods such as barbed sutures and skin adhesives., Methods: A Delphi panel, comprising seven orthopaedic surgeons, one musculoskeletal infectious disease specialist, and one health economics expert, was convened to evaluate the use of barbed sutures and skin adhesives for wound closure in hip and knee arthroplasty. Two systematic reviews informed the development of questionnaires, with panelists ranking their agreement on statements using a 5-point Likert scale. Consensus was achieved if ≥75% agreement. Unresolved statements were revisited in a second round., Results: Consensus was reached on 11 statements, providing evidence-based recommendations. The expert panel advocates for a multilayer watertight technique using barbed sutures to prevent surgical site infections (SSI), reduce complications, shorten surgical times, optimise resources and improve cosmetic appearance. For skin closure, the panel recommends topical adhesives to decrease wound dehiscence, enhance cosmetic appearance, promote patient compliance, prevent SSIs, and optimise resources., Conclusion: The Delphi consensus by Italian total joint arthroplasty experts underscores the pivotal role of barbed sutures and skin adhesives in optimising outcomes. While guiding clinical decision-making, these recommendations are not prescriptive and should be adapted to local practices. The study encourages further research to enhance current evidence., Level of Evidence: Level III., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Lorenzo Pradelli,1 Tiziana Sinigaglia,1 Alberto Migliore,2 Giovanni Antonio Checchia,3 Francesco Franceschi,4 Bruno Frediani,5 Florenzo Iannone,6 Emilio Romanini7 1AdRes HE&OR, Torino, Italy; 2Saint Peter Hospital, Rome, Italy; 3Hospital of Monselice, Padua, Italy; 4University Hospital of Rome, Rome, Italy; 5Hospital of Siena, Siena, Italy; 6University of Bari, Bari, Italy; 7RomaPro Center for Hip and Knee Arthroplasty, polo Sanitario San Feliciano, Rome, ItalyCorrespondence: Lorenzo Pradelli Email l.pradelli@adreshe.comAbstract: The aim of this document is to provide a set of indications on the national best practice management of knee osteoarthritis based on an analysis of the existing literature and the contribution of experts in the field. During the first phase of the project, in agreement with the multidisciplinary panel of experts, the main guidelines on the topic were selected. Each guideline was assessed through the AGREEII system to identify their strong/weak points and a summary of the recommendations contained in the various documents was drawn up. The panel drew up a list of therapeutic options to be included in the document and some of these topics were selected for in-depth analysis and review. The search strategy for the required literature reviews was constructed using the PICOS approach. The results obtained from the literature reviews, the in-depth analyses conducted by the members of the scientific societies involved and the analysis of the existing guidelines enabled an initial draft of the consensus document to be elaborated. This document was examined at the consensus conference held on 28 May 2019, in the presence of a multidisciplinary group consisting of members of the various scientific societies involved. Single recommendations were discussed in work groups with a view to combining the indications given by the literature examined with the experience of the specialists involved. The recommendations discussed were then put to the vote in a plenary assembly. The final document contains 26 practice recommendations which leading specialists involved in the management of knee OA in Italy agree upon.Keywords: knee osteoarthritis, conservative management, multidisciplinary consensus, Italy

Background: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success., Methods: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices., Results: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care., Conclusions: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background : Proximal humeral fractures (PHFs) are common, especially in the elderly, and account for 4% to 10% of all fractures, with women more often affected than men. Treatments include conservative methods, internal fixation and arthroplasty, with surgical approaches increasingly being used due to technological advancements. This study analyzes the evolution of PHF treatments in Italy from 2001 to 2022, using data from the Italian Hospital Discharge Records (HDRs) Database, and includes a stratified analysis by age and sex. Methods : Using HDR data from 2001 to 2022, records with ICD9-CM codes for proximal humeral fractures (812.0 and 812.1) among diagnoses were selected and categorized into three treatment groups: arthroplasty, fixation and conservative. Time series were analyzed with stratification by sex and age. Results : The extracted data included 486,368 records of PHFs, with 223,742 cases treated surgically (arthroplasty or internal fixation) and 262,626 treated conservatively; the average patient age was 66.6 years, with a higher proportion of women, especially among arthroplasty patients. Over time, the use of fixation and arthroplasty increased from 20% of treatments in 2001 to over 60% in 2022, with fixation becoming the most common treatment method by 2014 and arthroplasty significantly increasing among women, particularly in the 65-74 and 75-84 age groups. Conclusions : The study shows that in Italy, over the past two decades, treatment for PHFs has shifted from conservative methods to a preference for internal fixation and increasingly for arthroplasty, particularly among women and patients aged 65-84, reflecting evolving trends and technological improvements.

Introduction: The rupture of the plantar fascia is a rare but significant injury that predominantly affects athletes and individuals engaged in high-impact activities. Sudden increases in physical activity, direct trauma, corticosteroid injections, and chronic degeneration from plantar fasciitis can predispose individuals to rupture. It can involve a complete or partial tear of the plantar fascia fibers, leading to a loss of structural integrity and functional support. The tear may occur at the origin, mid-portion, or insertion of the fascia. Spontaneous ruptures of the plantar fascia (occurring without any predisposing factors) are rarely observed in clinical practice. No guidelines or other unequivocal recommendations are available for this pathological condition., Method: A healthy 35-year-old male who works in an office setting and is a recreational cyclist with a silent clinical anamnesis experienced a spontaneous rupture of the plantar fascia of the left foot with no history of trauma. He exhibited significant localized tenderness and swelling in the medial arch of the left foot with difficulty bearing weight on the affected foot. An MRI confirmed a partial rupture of the medial cord of the plantar fascia accompanied by surrounding inflammation. The patient underwent conservative treatment, which included rest, immobilization, physiotherapy (ultrasound therapy, high-power laser therapy, and transcutaneous electrical nerve stimulation), rehabilitation, and a gradual return to activity., Results: At the 12-week follow-up, the patient reported a significant reduction in pain and marked improvement in functional mobility (as confirmed by VAS and Foot Function Index scores). Physical examination showed no tenderness, and the patient could bear full weight on the foot without discomfort. A follow-up ultrasound demonstrated complete resolution of the plantar fascia rupture and no residual inflammation., Discussion: This case underscores the effectiveness of an integrated rehabilitative approach and provides a framework for managing similar cases in clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Venosa, Romanini, Vitale and Logroscino.)

Background: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures., Methods: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted., Results: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures., Conclusions: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective This study aimed to assess the quality of online patient educational materials regarding posterior cruciate ligament (PCL) reconstruction. Methods We performed a search of the top-50 results on Google® (terms: "posterior cruciate ligament reconstruction," "PCL reconstruction," "posterior cruciate ligament surgery," and "PCL surgery") and subsequently filtered to rule out duplicated/inaccessible websites or those containing only videos (67 websites included). Readability was assessed using six formulas: Flesch-Kincaid Reading Ease (FRE), Flesch-Kincaid Grade Level (FKG), Gunning Fog Score (GF), Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index (CLI), Automated Readability Index (ARI); quality was assessed using the JAMA benchmark criteria and recording the presence of the HONcode seal. Results The mean FRE was 49.3 (SD 11.2) and the mean FKG level was 8.09. These results were confirmed by the other readability formulae (average: GF 8.9; SMOG Index 7.3; CLI 14.7; ARI 6.5). A HONcode seal was available for 7.4 % of websites. The average JAMA score was 1.3. Conclusion The reading level of online patient materials concerning PCL reconstruction is too high for the average reader, requiring high comprehension skills. Practice implications Online medical information has been shown to influence patient healthcare decision processes. Patient-oriented educational materials should be clear and easy to understand., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Venosa et al.)

Background: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA)., Methods: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus., Results: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection)., Conclusions: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Grape seeds are a valuable source of natural phenolic compounds, particularly flavan-3-ol derivatives such as condensed tannins. Recent studies have shown that grape seed powder can be applied to reduce the undesirable effects of protein instability in wine. One pretreatment method applied to grape seeds is roasting. Roasting causes the heavier proanthocyanidins (PAC) oligomers to break down, thereby increasing the concentration of smaller oligomers available for interaction with proteins. In addition, roasting can prolong grape seed storage. Among the subclasses of proanthocyanidins, oligomeric macrocyclic proanthocyanidins have also shown potential effects in terms of wine stabilization, particularly by presenting selective interactions with metal cations such as potassium and calcium. However, their composition in grape seed extracts has never been studied. Here, the characterization of condensed tannins according to the degree of polymerization in grape seeds, the profile of cyclic proanthocyanidins and the total polyphenol content were characterized in relation to different grape varieties and the application of roasting. Roasting greatly influenced the distribution of PAC according to the degree of polymerization, increasing the abundance of almost all classes of PAC. However, the overall effect of roasting was highly dependent on grape variety. PAC were analyzed according to the degree of polymerization. Grape seed roasting of red varieties (Croatina and Sangiovese) showed an increase in all classes of PAC except trimers. The white variety (Ortrugo) and the mix of Nebbiolo and Barbera varieties (80% and 20% w/w, respectively) showed no clear effect on the profile of PAC upon roasting. Notably, cyclic procyanidins were identified for the first time in grape seeds: a cyclic tetrameric procyanidin (ESI + m/z 1153) and cyclic pentameric procyanidin (ESI + m/z 1441) were found. The abundances of these cyclic PAC were found to be completely stable upon roasting, also in agreement with the already known stability of these compounds against depolymerizing conditions. Interestingly, the cyclic pentameric procyanidin was significantly more abundant in Ortrugo (white variety), than in Sangiovese and Croatina (red varieties). Besides, no effect of roasting occurred on the profile of cyclic procyanidins in grape seed powder. Finally, the total polyphenol content was evaluated, showing that roasting caused an increase of polyphenolic molecular species potentially available for protein stabilization, but only in GSP of red varieties. Overall, the grape variety was found to be a significant factor in determining how much the roasting would change the PAC profile, providing valuable information for future applications of GSP in enology., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Total knee arthroplasty is an effective operation. Post-surgery rehabilitation, based on early and intensive progressive exercise programs, plays a substantial role and telerehabilitation can be an effective safe option. This retrospective study aimed to compare traditional in-presence rehabilitation and telerehabilitation for total knee arthroplasty, based on our experience during the Italian COVID-19 lockdown., Materials and Methods: We retrospectively analyzed 164 patients (94 females and 70 males) enrolled in 2020 within 2 weeks after total knee replacement to perform post-operative outpatient rehabilitation. The clinical results of 82 patients (mean age 66.8 ± 10.2 years) performing telerehabilitation with those obtained from a similar cohort of 82 patients (mean age 65.4 ± 11.8 years) performing traditional in-presence outpatient rehabilitation were compared. Clinical outcomes were examined by comparing the gait speed (Time Up and Go-TUG test), the range of motion, the pain intensity (VAS), the functional status (Oxford Knee Score-OKS and Knee injury and Osteoarthritis Outcome Score-KOOS) and the overall satisfaction (Self-administered patient satisfaction scale) 12 weeks after the beginning of the physiotherapeutic protocol., Results: Telerehabilitation was non-inferior to traditional in-presence rehabilitation in all of the investigated areas and no statistical difference in terms of effectiveness was detected at 12 weeks, as confirmed by the respective patient-reported outcome scores such as TUG test (reduced from 20 ± 2 s to 12 ± 1.5 s for the telerehab cohort and from 18 ± 1.5 s to 13.1 ± 2 s for the in-presence rehabilitation one), pain VAS, OKS (improved from 22 ± 1.3 to 36 ± 2.7 for the telerehab cohort and from 23 ± 2.1 to 35.1 ± 4.2 for the in-presence group), KOOS (improved from 46.2 ± 10.2 to 67.4 ± 3.8 for the telerehabilitation cohort and from 48.4 ± 8.4 to 68.3 ± 6.6 for the other group), and the Self-administered patient satisfaction scale (more than two-thirds of patients globally satisfied with the results of their surgery in both groups)., Conclusion: The telerehabilitation program was effective after total knee replacement and yielded clinical outcomes that were not inferior to conventional outpatient protocols.

Introduction: Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures., Materials and Methods: Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry., Results: This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program., Conclusions: This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.

Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Calò, Catena, Corsaro, Costantini, Falez, Moretti, Parrinello, Romanini, Spinarelli, Venneri, Vaccaro and Scientific Technical Committee.)

The management of perinatal HIV infection in preterm infants is hampered by the lack of evidence informing optimal antiretroviral treatment for these vulnerable newborns. We present a case of an extremely preterm infant with HIV infection treated immediately with a 3-drug antiretroviral regimen and achieving stable suppression of HIV plasma viral load., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Italian grape ale (IGA) beers have been categorized by the Beer Judge Certification Program as a sub-category of fruit beers in which grape, or grape must, is added during the brewing process to provide additional characteristics to the final beer. In the present work, IGA beers have been produced with must and pomace of the Malvasia di Candia Aromatica (MaCA) grape variety, which were added before fermentation at two different percentages (10% and 20%). The (poly)phenolic profile of IGA beers have been characterized with HPLC-MS/MS and compared to a golden ale control beer (produced in the same conditions without the addition of grape-derived ingredients). A series of sub-samples have been collected to monitor the (poly)phenol profile at time 0 and during the different phases of the fermentation process (1, 3, 5, 7 30, 65 days). Results demonstrated how the addition of pomace allowed to significantly enrich ( p < 0.05) final beers in total (poly)phenols detected by MS, while must addition did not influence that amount if compared to the control sample. However, a PCA cluster analysis identified strong similarities among IGA beers and differentiated them to control beer samples. This study underlined how the addition of must and pomace from the MaCA grape variety improved the (poly)phenolic profile of beer from both a qualitative and quantitative point of view.

The finding of USP9X variants in females has been associated with female-restricted X-linked mental retardation (MRXS99F), a rare syndrome featured by developmental delay and distinct congenital anomalies. Here, we report a female fetus with MRXS99F due to a novel frameshift variant, c.6679&#95;6685delAAATTATinsTCCTG (p.Lys2227SerfsTer2) in USP9X, which was present in a mosaic state in the amniocytes and in the peripheral blood after birth (14% and 30%, respectively). The X methylation status analysis displayed a partially skewed X-inactivation with 80% of inactive paternal X. The first signs of the MRXS99F were prenatally detected at 20 weeks, with an enlarged posterior cranial fossa, an upward rotation of the cerebellar vermis and partial corpus callosum agenesis, together with a cardiac septal defect and a single umbilical artery. After birth and during postnatal follow-up the anal anteriorization and the presence of a bilateral membranous choanal atresia were noted, whereas the MRI revealed the hypo/aplasia of the olfactory bulbs, a widening of the subarachnoid spaces and a delay in the myelinisation. During the 18-months follow-up a severe growth and global developmental delay, together with a bilateral moderate deafness with a threshold at 40 dB, dental enamel erosions and an initial scoliosis were observed. We report the prenatal and postnatal features of a classical MRXS99F phenotype and a mosaic USP9X frameshift variant with a partially skewed X inactivation and discuss genotype/phenotype correlations in view of the published studies so far., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

The emphasis on value-based payment models for primary total hip replacement (THA) results in a greater need for orthopaedic surgeons and hospitals to better understand actual costs and resource use. Time-Driven Activity-Based Costing (TDABC) is an innovative approach to measure expenses more accurately and address cost challenges. It estimates the quantity of time and the cost per unit of time of each resource (e.g., equipment and personnel) used across an episode of care. Our goal is to understand the true cost of a THA using the TDABC in an Italian public hospital and to comprehend how the adoption of this method might enhance the process of providing healthcare from an organizational and financial standpoint. During 2019, the main activities required for total hip replacement surgery, the operators involved, and the intraoperative consumables were identified. A process map was produced to identify the patient's concrete path during hospitalization and the length of stay was also recorded. The total inpatient cost of THA, net of all indirect costs normally included in a DRG-based reimbursement, was about EUR 6000. The observation of a total of 90 patients identified 2 main expense items: the prosthetic device alone represents 50.4% of the total cost, followed by the hospitalization, which constitutes 41.5%. TDABC has proven to be a precise method for determining the cost of the healthcare delivery process for THA, considering facilities, equipment, and staff employed. The process map made it possible to identify waste and redundancies. Surgeons should be aware that the choice of prosthetic device and that a lack of pre-planning for discharge can exponentially alter the hospital expenditure for a patient undergoing primary THA.

Objective: Liner dissociation (LD) is a rare catastrophic mechanical failure of total hip arthroplasty (THA). The study aims at reviewing the available literature regarding liner dissociations to point out their prevalence, describing any possible association and highlighting the surgical management at the time of revision., Materials and Methods: A systematic review of the literature was conducted from January 2002, until February 2022, according to the PRISMA guidelines. The main keywords were: "dissociation" AND "liner" OR "hip arthroplasty" OR "THA" and their MeSH terms in any possible combination. Cases of liner dissociation with all levels of evidence of any age published in indexed journals were included. The study quality of all included studies was evaluated using the MINORS criteria. The kappa (k) value was used to assess the consensus between reviewers in the selection of articles and methodological quality assessment. Finally, a sub-analysis was performed specifically concerning the elderly population., Results: Thirty-one manuscripts met the inclusion criteria of the systematic review (21 case reports and 10 case series). 124 LD in 123 patients, (53% females and 47% males) were evaluated. The overall prevalence of LD was 0.15%. The mean age at surgery was of 56.5 years (range 31-75 years). LD occurred in a primary surgery setting in 86% of the cases, at a mean time of presentation of 45.8 months after replacement surgery. 39.5% of the cups and 8.8% of the stems required revision. The mean follow-up after the revision was 18.4 months. Complications after revision occurred in 19.6% of cases, including 3 cases of re-dissociations. Re-revision was required in 13.6% of the revisions. The sub-analysis of the elderly population included 28 cases of LD identified in 10 manuscripts, with an average age of 73.5 years., Conclusions: LD is a rare but catastrophic mechanical complication of modular THA that requires implant revision. The LD is not related to a specific prosthetic implant, liner material or design, acetabular positioning within the safe zone or age group.