Aims. Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures. Methods. A retrospective cohort analysis of young adults (aged < 50 years) undergoing THA between May 2018 and May 2023 in a single tertiary centre was undertaken. Median follow-up was 31 months (12 to 61). Oxford Hip Score (OHS) and focus group-designed questionnaires were distributed. Searches identified 244 cases in 225 patients. Those aged aged under 30 years represented 22.7% of the cohort. Developmental dysplasia of the hip (50; 45.5%) and Perthes’ disease (15; 13.6%) were the commonest indications for THA. Results. Preoperatively, of 110 patients, 19 (17.2%) were unable to work before THA, 57 (52%) required opioid analgesia, 51 (46.4%) were reliant upon walking aids, and 70 (63.6%) had sexual activity limited by their pathology. One patient required revision due to instability. Mean OHS was 39 (9 to 48). There was a significant difference between the OHS of cases where THA met expectation, compared with the OHS when it did not (satisfied: 86 (78.2%), OHS: 41.2 (36.1%) vs non-satisfied: 24 (21%), OHS: 31.6; p ≤ 0.001). Only one of the 83 patients (75.5%) who returned to premorbid levels of activity did so after 12 months. Conclusion. Satisfaction rates of THA in young adults is high, albeit lower than commonly quoted figures. Young adults awaiting THA have poor function with high requirements for mobility aids, analgesia, and difficulties in working and undertaking leisure activities. The OHS provided a useful insight into patient function and was predictive of satisfaction rates, although it did not address the specific demands of young adults undertaking THA. Function at one year postoperatively is a good indication of overall outcomes. Cite this article: Bone Jt Open 2024;5(4):304–311

Different pathologies, deformities, bone defects, previous surgeries and polyethylene wear limit the survival of total hip arthroplasty (THA) in young patients. We compare preoperative status and outcome in 171 young and very young patients (207 hips) who underwent a ceramic-on-ceramic THA. Sixty-three (77 hips) were less than 30 years old (group 1) and 108 (130) were between 30 and 40 years old. Mean follow-up was 11.3 years. Two-way ANOVA with repeated measures were used to analyse clinical and radiological changes. Juvenile rheumatoid arthritis (JRA) was the most frequent diagnosis in group 1 and avascular necrosis in group 2. Charnley class type C, low activivity, previous surgery and osteoporotic bone were more frequent in group 1 patients. There were 2 cup revisions for aseptic loosening in group 1 and 4 in group 2. Survivorship analysis at 15 years was 96.7% (95% IC 92.2 a 100) for group 1 and 96.1% (95% IC 92.2 to 100) for group 2 (p=0.749). Despite the worse preoperative status in group 1 patients, clinical outcome was similar in both groups. Severe dysplasia had the worst clinical result and avascular necrosis the best. Patients with Charnley class C and JRA showed the most improvement. Radiographic reconstruction of the abduction angle was worse in group 1 (p=0.02). No osteolysis or complications derived from ceramic use were found. We conclude that despite the worse preoperative status in group 1 patients, clinical and radiographic results were good in both groups of patients who received a ceramic-on-ceramic THA

Background and aim. Total hip replacement (THR) in young patients has been associated to higher revision rates than in older population. Different conditions may lead to end-stage arthritis of the hip in these patients. We compared the clinical and radiological outcome of two different groups of young and very young patients who underwent a ceramic-on-ceramic THR. Patients and Methods. 120 hips were prospectively followed for a mean of 10.4 years (range, 5 to 17). 38 patients (46 hips) were less than 30 years old (group 1), and, 68 (74 hips) were between 31 and 40 years old (group 2). Weight (p<0.001) and physical activity level were greater in group 2 (p<0.001). Preoperative function (p=0.03) and range of mobility (p=0.03) were worse in group 1. Primary osteoarthritis was not found in any case. Rheumatoid juvenile arthritis was the most frequent diagnosis in group 1 and avascular necrosis of the femoral head in group 2. A femoral funnel-shaped type 1 according to Dorr was more frequent in group 2 (p=0.04). The same ceramic-on-ceramic uncemented THR was used in all cases. Screws for cup fixation were only used when strictly needed. We analysed the clinical results according to the Merle-D´Aubignè and Postel scale, the postoperative radiological reconstruction of the hip and the radiological appearance of cup loosening. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having a revision surgery. Results. Screw use required to obtain a secured interference fit of the acetabular component was found more frequently in group 1 (p=0.01). Postoperative pain (p=0.002) and function (p=0.002) were better in group 1. Mean acetabular abduction angle of the cup was greater in group 1 (p=0.03) and reconstruction to the hip rotation center according to Ranawat (p=0.01) was better in group 2. Placement of the acetabular component inside the Lewinnek´s zone and stem position were similar in both groups. No hips were revised due to complications related to ceramic or to stem loosening. Three cups were revised for aseptic loosening in group 1 and four in group 2. The survival rate for cup aseptic loosening at 15 years was 92.3% (95% CI: 83.7 to 100) for group 1 and 93.1% (95% CI: 85.3 to 99.9) for group 2 (Log rank, p=0.88). Conclusion. Ceramic-on-ceramic uncemented THR is an excellent option for young and very young patients. Despite worse preoperative conditions in patients under the age of 30 years, a similar clinical outcome was found in this series

Total hip replacement (THR) in young patients has been associated to higher revision rates than in older population. Different conditions may lead to end-stage arthritis of the hip in these patients. We compared the clinical and radiological outcome of two different groups of young and very young patients who underwent a ceramic-on-ceramic THR. 120 hips were prospectively followed for a mean of 10.4 years (range, 5 to 17). 38 patients (46 hips) were less than 30 years old (group 1), and, 68 (74 hips) were between 31 and 40 years old (group 2). Weight (p<0.001) and physical activity level were greater in group 2 (p<0.001). Preoperative function (p=0.03) and range of mobility (p=0.03) were worse in group 1. Primary osteoarthritis was not found in any case. Rheumatoid juvenile arthritis was the most frequent diagnosis in group 1 and avascular necrosis of the femoral head in group 2. A femoral funnel-shaped type 1 according to Dorr was more frequent in group 2 (p=0.04). The same ceramic-on-ceramic uncemented THR was used in all cases. Screws for cup fixation were only used when strictly needed. We analysed the clinical results according to the Merle-D´Aubignè and Postel scale, the postoperative radiological reconstruction of the hip and the radiological appearance of cup loosening. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having a revision surgery. Screw use required to obtain a secured interference fit of the acetabular component was found more frequently in group 1 (p=0.01). Postoperative pain (p=0.002) and function (p=0.002) were better in group 1. Mean acetabular abduction angle of the cup was greater in group 1 (p=0.03) and reconstruction to the hip rotation center according to Ranawat (p=0.01) was better in group 2. Placement of the acetabular component inside the Lewinnek´s zone and stem position were similar in both groups. No hips were revised due to complications related to ceramic or to stem loosening. Three cups were revised for aseptic loosening in group 1 and four in group 2. The survival rate for cup aseptic loosening at 15 years was 92.3% (95% CI: 83.7 to 100) for group 1 and 93.1% (95% CI: 85.3 to 99.9) for group 2 (Log rank, p=0.88). Ceramic-on-ceramic uncemented THR is an excellent option for young and very young patients. Despite worse preoperative conditions in patients under the age of 30 years, a similar clinical outcome was found in this series

It is known that the gait dynamics of elderly substantially differs from that of young people. However, it has not been well studied how this age-related gait dynamics affects the knee biomechanics, e.g., cartilage mechanical response. In this study, we investigated how aging affects knee biomechanics in a female population using subject-specific computational models. Two female subjects (ages of 23 and 69) with no musculoskeletal disorders were recruited. Korea National Institute for Bioethics Policy Review Board approved the study. Participants walked at a self-selected speed (SWS), 110% of SWS, and 120% of SWS on 10 m flat ground. Three-dimensional marker trajectories and ground reaction forces (Motion Analysis, USA), and lower limbs’ muscle activities were measured (EMG, Noraxon USA). Knee cartilage and menisci geometries were obtained from subjects’ magnetic resonance images (3T, GE Health Care). An EMG-assisted musculoskeletal finite element modeling workflow was used to estimate knee cartilage tissue mechanics in walking trials. Knee cartilage and menisci were modeled using a transversely isotropic poroviscoelastic material model. Walking speed in SWS, 110%, and 120% of SWS were 1.38 m/s, 1.51 m/s, and 1.65 m/s for the young, and 1.21 m/s, 1.34 m/s and 1.46 m/s for the elderly, respectively. The maximum tensile stress in the elderly tibial cartilage was ~25%, ~33%, and ~32% lower than the young at SWS, 110%, and 120% of SWS, respectively. These preliminary results suggest that the cartilage in the elderly may not have enough stimulation even at 20% increases in walking speed, which may be one reason for tissue degeneration. To enhance these findings, further study with more subjects and different genders will investigate how age-related gait dynamics affects knee biomechanics. Acknowledgments: Australian NHMRC Ideas Grant (APP2001734), KITECH (JE220006)

Management of ankle arthritis in young patients is challenging. Although ankle arthrodesis gives consistent pain relief, it leads to loss of function and adjacent joint arthritis. Ankle joint distraction (AJD) has been shown to give good outcomes in adults with osteoarthritis or post-traumatic arthritis. The efficacy in children or young adults and those with juvenile idiopathic arthritis is less well evidenced. Clinical notes and radiographs of all patients (n=6) managed with AJD in one tertiary referral centre were retrospectively reviewed. Radiographs were taken pre-surgery, intra-operatively, 1 month following frame removal and at the last follow up, tibiotalar joint space was assessed using ImageJ software. Measurements were taken at the medial, middle and lateral talar dome using frame components as reference. Radiographic data for patients with a good clinical outcome was compared with those who did not. At time of surgery mean age was 16.1 years (12 – 25 years). Mean follow up was 3.4 years (1.5 – 5.9 years). Indications were juvenile idiopathic arthritis (4) post-traumatic (1) and post-infective arthritis (1). Three patients at last follow up had a good clinical outcome. Two patients required revision to arthrodesis (1.3 and 2.4 years following distraction). One patient had spontaneous fusion. One patient required oral antibiotics for pin site infection. Inter-observer reliability was 95%. Mean joint space was 1.17mm (SD = 0.87mm) pre-operatively which increased to 6.72mm (SD = 2.23mm) at the time of distraction and 2.09mm (SD = 1.14mm) at the time of removal. At one-year follow up, mean joint space was 1.96mm (SD = 1.97mm). Outcomes following AJD in this population are variable although significant benefits were demonstrated for 50% of the patients in this series. Radiographic joint space preoperatively did not appear to be associated with need for arthrodesis. Further research in larger groups of young patients is required

Introduction and Objective. Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity. Materials and Methods. A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this. Results. There were three thematic models developed in the data set, which then were further divided into subthemes. Model 1: Negative Health Behaviour Prior to Treatment, model 2: Feeling Frail and model 3: Need for Speed. Model 1 corroborated that participants were inclined to sustain the injury as a result of risk-taking and would subsequently hesitate to seek treatment. Model 2 indicated that as a result of the injury, respondents were unable to engage in physical activities and activities of daily living. Respondents exercised caution to varying extents after sustaining a SWF. Model 3 highlighted that interviewees were prone to non-adherence with fracture immobilisation and in hindsight resumed employment prematurely. Conclusions. The findings of this study demonstrate that masculinity is significantly influential on the experience of SWF in young men. This was indicated through the results of thematic analysis strongly corresponding with behaviours established in men's health literature. Educational interventions could be of value in addressing behaviours observed in this population group, such as delayed help-seeking and non-compliance with fracture immobilisation. Further work in patient education and concordance with treatment after sustaining a SWF may be beneficial to longer term outcomes. In turn, this may reduce complications associated with SWF in young men

Young patients undergoing THA or hip used. HOS and iHOT33 have demonstrated to be useful in hip preservation surgery but never used in THA. The aim of the study was to evaluate long-term clinical outcomes with HOS and iHOT33 in hip arthroscopy and THA. We conducted a retrospective study with prospective data collection of 118 consecutive young patients (<65 y.o.) between 2008 to 2012 who underwent hip arthroscopy or THA. The mean follow-up was 12.05 years. All surgeries were done by the same senior surgeon. PROMs used were iHOT-33 and HOS preoperatively, at one year and 10 years. SPSS Statistics Grad Pack 28.0 software was used for statistical analysis. Arthroscopy Group (57 patients): Mean age 35.36 years. 55.93% were male. iHOT33 mean differential improvement was 24.43 at 1 year, 70,17% exceed MCID and 49,1% SCB. HOS mean differential improvement was 16.26 at one year. 54,38 % patients exceed MCID and 49,36% SCB. At 10 years, iHOT33 mean differential improvement was 14,36 and 12.56 for HOS. Regarding complications, 3 patients underwent THA (5.26%) and 10 (17.54%) continued with groin pain. THA Group (61 patients): Mean age 52,54 years. 55.73% were male. Cementless THA was used in all patients with ceramic on ceramic used in 77%. iHOT33 mean differential improvement was 41,57 at 1 year. 95,08% patients exceed MCID and 85,25% SCB. HOS mean differential improvement was 16.57 points at one year. 85,25% patients exceed MCID and 81,97% SCB. At 10 years, iHOT33 mean differential improvement was 20,15 and 14.12 for HOS. Regarding complications, 1 patient underwent DAIR for infection (1.64%) and 1 dislocation with close reduction (1.64%). iHOT33 or HOS scores should be considered to be used in young active patients after hip preserving surgery or THA, with more predictable results at long-term in THA group

Aims. The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group). Methods. This was a case-control study of consecutive patients receiving a posterior-stabilized TKA for OA between 1996 and 2010 with previous HTO. A total of 73 TKAs after HTO with minimum ten years’ follow-up were included. Cases were matched with a TKA without previous HTO for age at the time of the HTO. All revisions were recorded. Kaplan-Meier survivorship analysis was performed using revision of metal component as the endpoint. The Knee Society Score, range of motion, and patient satisfaction were assessed. Results. Mean follow-up was 13 years (SD 3) after TKA in both groups. The 20-year Kaplan-Meier survival estimate was 98.6% in TKA post-HTO group (HTO as timing reference) and 81.4% in control group (TKA as timing reference) (p = 0.030). There was no significant difference in clinical outcomes, radiological outcomes, and complications at the last follow-up. Conclusion. At the same delay from index surgery (HTO or TKA), a strategy of HTO followed by TKA had superior knee survivorship compared to early TKA at long term in young patients. Level of evidence: III. Cite this article: Bone Jt Open 2023;4(2):62–71

Femoral head necrosis in the context of high impact gymnastics of young adolescents is rare but seems a more serious complication compared to a Perthes like necrosis. Between 2017 and 2019, three young females aged from12 to 14 years were referred due incapacitating hip pain and severe collapsing femoral head necrosis. The indication of hip preserving surgery was based on the extent of the necrosis, presence of a vital lateral pillar and joint subluxation. In one of our 3 cases total head involvement made THR necessary, which was performed elsewhere. In the remaining 2 cases, head reduction osteotomy plus periacetabular osteotomy led to a good and a fair result. Repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension/ external rotation could be the cause of severe femoral head necrosis in three adolescent female gymnasts we are reporting on. Supra-selective angiography or sonography may be helpful to improve indication. Targeted adaptation of training methods should be discussed. Due to the severe vascular insult, results have to be considered moderate

Mesenchymal stromal cells (MSC) have been proposed as an emerging cell therapy for bone tissue engineering applications. However, the healing capacity of the bone tissue is often compromised by patient's age and comorbidities, such as osteoporosis. In this context, it is important to understand the impact of donor age on the therapeutic potential of MSC. Importantly, the impact on donor age is not restricted to cells themselves but also to their microenvironment that is known to affect cell function. The extracellular matrix (ECM) has an important role in stem cell microenvironment, being able to modulate cell proliferation, self-renewal and differentiation. Decellularized cell-derived ECM (dECM) has been explored for regenerative medicine applications due to its bioactivity and its resemblance to the in vivo microenvironment. Thus, dECM offers the opportunity not only to develop microenvironments with customizable properties for improvement of cellular functions but also as a platform to study cellular niches in health and disease. In this study, we investigated the capacity of the microenvironment to rescue the impaired proliferative and osteogenic potential of aged MSC. The goal of this work was to understand if the osteogenic capacity of MSC could be modulated by exposure to a dECM derived from cells obtained from young donors. When aged MSC were cultured on dECM derived from young MSC, their in vitro proliferative and osteogenic capacities were enhanced. Our results suggest that the microenvironment, specifically the ECM, plays a crucial role in the osteogenic differentiation capacity of MSC. dECM might be a valuable clinical strategy to overcome the age-related decline in the osteogenic potential of MSC by recapitulating a younger microenvironment, attenuating the effects of aging on the stem cell niche. Overall, this study opens new possibilities for developing clinical strategies for elderly patients with limited bone formation capacity who currently lack effective treatments. Acknowledgements: The authors thank FCT for funding through the project DentalBioMatrix (PTDC/BTM-MAT/3538/2020) and to the research institutions iBB (UIDB/04565/2020 and UIDP/04565/2020) and Associate Laboratory i4HB (LA/P/0140/2020)

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated. During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient. Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations

Shoulder arthritis in the young adult is a deceptive title. The literature is filled with articles that separate outcomes based on an arbitrary age threshold and attempt to provide recommendations for management and even potential criteria for implanting one strategy over another using age as the primary determinant. However, under the age of 50, as few as one out of five patients will have arthritis that can be accurately classified as osteoarthritis. Other conditions such as post-traumatic arthritis, post-surgical arthritis including capsulorrhaphy arthropathy, and rheumatoid arthritis create a mosaic of pathologic bone and soft tissue changes in our younger patients that distort the conclusions regarding “shoulder arthritis” in the young adult. In addition, we are now seeing more patients with unique conditions that are still poorly understood, including arthritis of the pharmacologically performance-enhanced shoulder. Early arthritis in the young adult is often recognised at the time of arthroscopic surgery performed for other preoperative indications. Palliative treatment is the first option, which equals “debridement.” If the procedure fails to resolve the symptoms, and the symptoms can be localised to an intra-articular source, then additional treatment options may include a variety of cartilage restoration procedures that have been developed primarily for the knee and then subsequently used in the shoulder, including microfracture, and osteochondral grafting. The results of these treatments have been rarely reported with only case series and expert opinion to support their use. When arthritis is moderate or severe in young adults, non-arthroplasty interventions have included arthroscopic capsular release, debridement, acromioplasty, distal clavicle resection, microfracture, osteophyte debridement, axillary nerve neurolysis, and bicep tenotomy or tenodesis, or some combination of these techniques. Again, the literature is very limited, with most case series less than 5 years of follow-up. The results are typically acceptable for pain relief, some functional improvement, but not restoration to completely normal function from the patient's perspective. Attempts to resurface the arthritic joint have resulted in limited benefits over a short period of time in most studies. While a few remarkable procedures have provided reasonable outcomes, they are typically in the hands of the developer of the procedure and subsequently, other surgeons fail to achieve the same results. This has been the case with fascia lata grafting of the glenoid, dermal allografts, meniscal allografts, and even biologic resurfacing with large osteochondral grafts for osteoarthritis. Most surgical interventions that show high value in terms of improvement in quality of life require 10-year follow-up. It is unlikely that any of these arthroscopic procedures or resurfacing procedures will provide outcomes that would be valuable in terms of population healthcare; they are currently used on an individual basis to try to delay progression to arthroplasty, with surgeon bias based on personal experience, training, or expert opinion. Arthroplasty in the young adult remains controversial. Without question, study after study supports total shoulder arthroplasty over hemiarthroplasty once the decision has been made that joint replacement is the only remaining option

Introduction. Patient-specific instruments (PSI) and surgical-guiding templates are gaining popularity as a tool for enhancing surgical accuracy in the correction of oblique bone deformities Three-dimensional virtual surgical planning technology has advanced applications in the correction of deformities of long bones and enables the production of 3D stereolithographic models and PSI based upon a patient's specific deformity. We describe the implementation of this technology in young patients who required a corrective osteotomy for a complex three-plane (oblique plane) lower-limb deformity. Materials and Methods. Radiographs and computerized tomographic (CT) scans (0.5 mm slices) were obtained for each patient. The CT images were imported into post-processing software, and virtual 3D models were created by a segmentation process. Femoral and tibial models and cutting guides with locking points were designed according to the deformity correction plan as designed by the surgeon. The models were used for preoperative planning and as an intraoperative guide. All osteotomies were performed with the PSI secured in the planned position. Results. A total of 17 patients (9 males and 8 females, average age 14.7 years [range 8–24]) comprised the study group. All of the PSI were excellent fits for the planned bone surfaces during surgery. The osteotomies matched the preoperative planning simulation and allowed for easy fixation with pre-chosen plates. No intra- or postoperative complications were encountered. Surgery time was shortened (101 minutes) and intraoperative blood loose was less compared to historical cases. Clinical and radiographic follow-up findings showed highly satisfactory alignment of the treated extremities in all 17 patients. Conclusions. The use of 3D-printed models and patient-specific cutting guides with locking points increases accuracy, shortens procedure time, reduces intraoperative blood loss, and improves the outcome of osteotomies in young patients with complex oblique bone deformities

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Introduction. Modular dual mobility (MDM) prostheses are increasingly utilized for total hip arthroplasty (THA) to mitigate the risk of postoperative instability in high risk patients. Short-term reports on clinical outcomes are favorable but there are few studies on young active patients. This study quantified proximal femoral stress shielding and metal ion release in MDM combined with modern cementless stem design in young active patients. Methods. This was a prospective study of patients between 18 and 65 years of age, with a body mass index (BMI) < 35 kg/m2 and University of California at Los Angeles (UCLA) activity score > 6, who received a modular cobalt-chromium acetabular liner, highly crosslinked polyethylene mobile bearing, and cementless titanium femoral stem for their primary THA. DEXA scans were performed at 6 weeks postoperatively as a baseline, then again at 6 months, 1 year, 2 years and 5 years postoperatively as were metal ions. Results. A total of 43 patients (30 male, 13 female; mean age 52.6 years (sd 6.5)) were enrolled. At the time of analysis, 14 patients had completed DEXA scans at 5 years postoperatively. There was no significant loss of proximal femoral bone mineral density in Gruen Zones 1–7 or acetabular bone mineral density in Gruen Zones 1–6 between 6 weeks and 5 years postoperatively (p > 0.05 for each zone). Sixteen patients had metal ions at 5yrs. Cobalt levels averaged .07 ppb (range .012 – .451) and chromium levels averaged 0.24 ppb (range .092 – .883). Conclusion. At a minimum 5 years follow up, MDM with a modern cementless stem demonstrated minimal stress shielding and no concerning metal ion release in young active patients

Aims. Modular dual mobility (DM) prostheses in which a cobalt-chromium liner is inserted into a titanium acetabular shell (vs a monoblock acetabular component) have the advantage of allowing supplementary screw fixation, but the potential for corrosion between the liner and acetabulum has raised concerns. While DM prostheses have shown improved stability in patients deemed ‘high-risk’ for dislocation undergoing total hip arthroplasty (THA), their performance in young, active patients has not been reported. This study’s purpose was to assess clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) in young, active patients receiving a modular DM acetabulum and recently introduced titanium, proximally coated, tapered femoral stem design. Patients and Methods. This was a prospective study of patients between 18 and 65 years of age, with a body mass index (BMI) < 35 kg/m. 2. and University of California at Los Angeles (UCLA) activity score > 6, who received a modular cobalt-chromium acetabular liner, highly crosslinked polyethylene mobile bearing, and cementless titanium femoral stem for their primary THA. Patients with a history of renal disease and metal hardware elsewhere in the body were excluded. A total of 43 patients (30 male, 13 female; mean age 52.6 years (. sd. 6.5)) were enrolled. All patients had a minimum of two years’ clinical follow-up. Patient-reported outcome measures, whole blood metal ion levels (ug/l), and periprosthetic femoral BMD were measured at baseline, as well as at one and two years postoperatively. Power analysis indicated 40 patients necessary to demonstrate a five-fold increase in cobalt levels from baseline (alpha = 0.05, beta = 0.80). A mixed model with repeated measures was used for statistical analysis. Results. Mean Harris Hip Scores improved from 54.1 (. sd. 20.5) to 91.2 (. sd. 10.8) at two years postoperatively (p < 0.001). All patients had radiologically well-fixed components, no patients experienced any instability, and no patients required any further intervention. Mean cobalt levels increased from 0.065 ug/l (. sd. 0.03) preoperatively to 0.30 ug/l (. sd. 0.51) at one year postoperatively (p = 0.01) but decreased at two years postoperatively to 0.16 ug/l (. sd. 0.23; p = 0.2). Four patients (9.3%) had a cobalt level outside the reference range (0.03 ug/l to 0.29 ug/l) at two years postoperatively, with values from 0.32 ug/l to 0.94 ug/l. The mean femoral BMD ratio was maintained in Gruen zones 2 to 7 at both one and two years postoperatively using this stem design. At two years postoperatively, mean BMD in the medial calcar was 101.5% of the baseline value. Conclusion. Use of a modular DM prosthesis and cementless, tapered femoral stem has shown encouraging results in young, active patients undergoing primary THA. Elevation in mean cobalt levels and the presence of four patients outside the reference range at two years postoperatively demonstrates the necessity of continued surveillance in this cohort. Cite this article: Bone Joint J 2019;101-B:365–371

This retrospective study was to investigate radiographic and clinical outcomes in treatment of hip instability in children and young adults undergoing periacetabular osteotomy (PAO) with or without femoral osteotomy. 19 patients (21 hips) with CP were treated with PAO with or without femoral osteotomy The mean age was 16.2 years old (7 to 28 years). Five patients (5 hips) received PAO, Six patients (7 hips) PAO with femoral derotation osteotomy, Eight patients (9 hips) PAO with varus derotational osteotomy (VDRO). Anteroposterior pelvic radiographs and CT were taken to assess the migration percentage (MP), lateral center-edge angle (LCEA), Sharp angle, femoral neck anteversion, neck-shaft angle. Gross Motor Function Classification System (GMFCS) was assessed pre- and post-surgery. Complications were recorded. The mean follow-up time was 41.2 months (range, 24 to 86 months). All hips but one were pain free at final visit. The GMFCS improved by one level in 10 of 19 patients. MP improved from a mean of 76.6% to 18.6% at the final follow-up(p<0.001). The mean pre-operative LCEA and Sharp angle were −33.5 ? and 35 ? respectively, improved to 21.5 ? and 11.8 ? at the final follow-up (p < 0.001). There were six patients (7 hips) had re-subluxation at latest follow-up. Nervus cutaneus femoris lateralis was impaired in four patients after surgery. There was no re-dislocation, AVN, or infections in this group. Satisfactory clinical and radiologic results can be obtained by PAO with or without femoral osteotomy minor complications

Total hip arthroplasty (THA) is effective, reproducible, and durable in the treatment of hip joint arthritis. While improvements in polyethylene materials have significantly reduced wear rates and osteolysis, aseptic loosening of implants remains one of the leading causes of revision THA. Additionally, fears of dislocation and instability have driven the increase in the utilization of larger diameter femoral heads in primary THA which can lead to increased wear when coupled with a polyethylene articulation. Finally, the increasing number of younger and active patients undergoing THA raises questions with regards to the ability of modern conventional bearings to provide durability and longevity beyond second and third decades following joint implantation. Ceramic-on-ceramic articulations are ideally suited for today's young and high demand patients undergoing primary THA. It has the lowest in-vitro wear properties of any bearing couple and the wear characteristics are further improved by its wettability and lubrication particularly when larger heads are utilised. Additionally, improvements in material properties and prosthesis design have significantly decreased fracture rates and increased the reliability of these implants. Furthermore, reported outcomes and longevity of modern ceramic-on-ceramic THAs in younger patients have all shown excellent survivorship despite patients achieving and maintaining a very high level of activity and function. In short, it is the bearing couple most in tune with current market demands and utilization trends. While registry data and meta-analyses of published literature have failed to show the superiority of ceramic-on-ceramic articulations compared to conventional bearings at 10 years, there is evidence that even highly crosslinked polyethylene (HXPE) is not immune to wear. Selvarajah et al. reported steady, in-vivo wear rates of HXPE exceeding 0.1mm/year threshold in young THA patients with 36mm ceramic ball heads. Additionally, small osteolytic lesions have been observed in hips with HXPE bearings at 12–14 years follow up. Finally, analysis of all controlled randomised studies have shown less osteolysis of ceramic-on-ceramic hips compared to polyethylene articulations. The significance of these lesions are unclear but the question remains: Can HXPE as a bearing be able to provide over 30 years of service needed to outlast patients younger than 60 years?. Concerns with cost, squeaking, and fractures do not make ceramic-on-ceramic bearings suitable for all patients undergoing primary THA. However, in young, healthy and active patients, a modern ceramic- on-ceramic articulation is most likely to provide the lowest wear rates, lowest risk of osteolysis, and greatest chance for life-long durability

We describe the clinical and radiological results of thirty eight consecutive total hip replacements, using the JRI Furlong Hydroxyapatite ceramic coated femoral component (JRI Instrumentation Ltd, London, UK) in patients under the age of 50 at the time of surgery. The mean age at the time of operation was 42 years (range 22 to 49 years). The average length of follow up was 10 years (range 63 to 170 months). All patients receiving a Furlong HAC THR were included regardless of their primary aetiology. These included patients on whom previous hip joint surgery had taken place. The mean Harris hip score improved from 44 pre-operatively to 92 at the latest post-operative review. The mean WOMAC and Oxford scores at the latest review for this study were 29 and 16 respectively. Using the Charnley modification of the Merle d’Aubign_ and Postel hip score, at the latest follow up the mean scores were as follows: Pain 5.37, Function 5.47, and Range of Motion 5.71. The mean pain visual analogue score was 1.1 and 94% of patients returned to outdoor activities or sports. There were no reports of thigh pain at any review. There was no loss to follow-up. There were no revisions of any femoral component. Radiological review of the femoral components revealed no continuous or progressive radiolucent lines around the stem. No osteolysis was noted. Using revision or impending revision as the end point at 12 years the cumulative survival for the stem was 100% (95% CI 89 to 100). We present excellent clinical, radiological and survivrship results with the use of HAC components in young, active patients with varying primary pathology, after ten years use