Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique.

89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months.

All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies.

Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity.

Pre-operative definitive diagnosis of infection in painful total hip arthroplasty (THA) is not always easy to be established, making the intra-operative decision-making process crucial in management of revision hip surgery. Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJIs.

From November 2020 to December 2022, 105 patients with painful primary THA were treated with revision THA in 3 orthopaedic departments. Pre-operatively, 23 were considered infected and treated with two-stage revision THA. The remaining 82 were likely infected according to the 2019 EBJIS criteria. The suspicion of low-grade infection was based on clinical (rest and/or night pain), laboratory (CRP, ESR, WBC – normal or slightly elevated) and radiological evaluation (loosening). Hip aspiration under CT imaging was performed in these cases and 34 of them yielded positive culture and were treated with two-stage revision. Aspiration was ineffective in the remaining 48 cases (33 negative, 15 unsuccessful attempts). Intra-operatively, calprotectin was measured with lateral flow immunoassay test in these patients. Cases with calprotectin levels ≥ 50 mg/L were treated with 2-stage revision THA; otherwise, they were considered not-infected and one-stage revision was performed. Synovial fluid and tissue samples were collected for analysis. Implants were sent for sonication fluid cultures.

Calprotectin was positive (≥ 50 mg/L) in 27 cases and negative in 21 cases. There was 1 false negative case with positive tissue cultures. Out of the 27 positive cases, 25 had positive tissue cultures and sonication. However, 2 cases with high calprotectin levels (>200 mg/L) were not infected. The false positive result was attributed to severe metallosis. Calprotectin sensitivity was 96.2%, specificity 90.9%, PPV 92.6%, NPV 95.2%, AUC 0.935.

The results of this ongoing study indicate that calprotectin seems to be a valuable tool in facilitating the intra-operative decision-making process in cases that low-grade infection is suspected and diagnosis cannot be established pre-operatively.

Hemiarthroplasty (HA) and total hip arthroplasty (THA) have both been well described as effective methods of management for displaced femoral neck fractures in the elderly. THA has superior functional outcomes and lower long-term revision rates, while HA is associated with lower dislocation rates and faster operative times. While HA remains an appropriate management option in low-demand patients, it is commonly complicated by acetabular erosion. However, there is no consensus about the preferred method of treatment in self-sufficient, physically active patients with normal cognition. The aim of this study was to evaluate the impact of age in geriatric patients with acetabular wear after bipolar HA.

We retrospectively reviewed the records of all cases of femoral neck fractures treated with bipolar HA in our institution, during the period 2013 – 2020. According to the age at the time of fracture, patients were separated in 3 groups: Group A (age 70 – 75), group B (age 75 – 80) and group C (age > 80). Acetabular wear was defined as failure of the acetabulum, which needed revision to THA.

A total of 1410 patients (861 females and 549 males, mean age 77,2 years) were included in the study. 359 patients were included in Group A, 592 in Group B and 459 in Group C. Mean follow-up was 3.2 years. There were no significant differences in sex distribution, injury side, fracture pattern, BMI, ASA score, bipolar head diameter and leg length discrepancy among the 3 groups. The incidence of acetabular wear and need for revision to THA was 6.13%, 4.22% and 1.96% respectively (p = 0.009).

The higher rate of acetabular wear in patients less than 75 years suggests that THA is a more viable option for these patients. In group 75–80 years old decision for HA or THA should be made upon patient's activity status and biological age while above the age of 80 years old, Hemi seems to be the preferred solution.

Porous tantalum is a highly osteoinductive biomaterial, initially introduced in orthopedics in 1997, with a subsequent rapid evolution of orthopedic applications. The use of porous tantalum for the acetabular component in primary total hip arthroplasty (THA) has demonstrated excellent short-term and mid-term results. However, long term data are scarce. The purpose of this prospective study is to report the long-term clinical and radiological outcome following use of an uncemented porous tantalum acetabular component in primary THA with a minimum follow-up of 17.5 years, in a previously studied cohort of patients.

We prospectively followed 128 consecutive primary THAs in 140 patients, between November 1997 and June 1999. A press-fit porous tantalum monoblock acetabular component was used in all cases. The presence of initial gaps in the polar region, as sign of incomplete seating of the monoblock cup, was assessed on the immediate postoperative radiographs. All patients were followed clinically and radiographically at 6, 12, and 24 weeks and 12 months and then at 2, 5, 8, 10, and 19 years, for a mean of 18.1 years (range 17.5 – 19 years). Periacetabular dome gap filling, acetabular cup migration and polyethylene wear were assessed by the EBRA digital measurement system, until 2 years postoperatively.

Mean age of patients at the time of operation was 60.4 years old (range 24 – 72). Harris hip score, Oxford Hip Score and range of motion (ROM) were dramatically improved in all cases (p < 0.001). In the initial postoperative radiographs, periacetabular dome gaps were observed in the 15% of cases, and were progressively filled within 6 months. In 2 years postoperatively, the mean component migration, as shown in EBRA study, was 0.67 mm. At last follow-up, all cups were radiographically stable with no evidence of migration, gross polyethylene wear, progressive radiolucencies, osteolytic lesions or acetabular fractures. The survivorship with re-operation for any reason as end point was 92.8%, whereas the survivorship for aseptic loosening as an end point was 100%. Upon visual inspection, two removed acetabular components due to recurrent dislocation and infection, respectively, showed extensive bone osseointegration.

In our primary THA series, the porous tantalum monoblock cup demonstrated excellent clinical and radiographic outcomes with no failures because of aseptic loosening at a mean follow-up of 18.1 years. Porous tantalum acetabular components showed excellent initial stability, produced less wear debris and revealed a great potential for bone ingrowth. Due to its unique osteoinductive properties and elliptical shape, porous tantalum monoblock cups have demonstrated superior short and long-term survivorship compared to other press fit prostheses in the market.

Periprosthetic knee infection is a serious complication of total knee replacement, connected to the formation of microbial biofilm on the surface of the implant. The most common bacteria causing periprosthetic infections are: Staphylococcus aureus, coagulase negative staphylococci and Gram negative bacteria. The purpose of this study is to present a rare case of periprosthetic knee infection caused by Ralstonia pickettii, which ultimately resulted in knee arthrodesis.

A 70 years old patient was referred to our clinic because of persistent pain, swelling and fistula in his left knee, 18 months after total knee arthroplasty. The patient had received oral ciprofloxacin and rifampicin during the last three months. The cultures of the fistula and knee aspiration were negative. A 2-stages revision of the total knee arthroplasty was decided. The patient underwent surgical removal of the prosthesis, cement and suspicious tissues and a spacer was placed. Samples from periprosthetic tissues were sent for conventional culture and all metal components were sonicated.

Intraoperative periprosthetic tissue cultures were negative. The culture of the sonicated fluid was positive for Ralstonia pickettii, a finding which was confirmed by the method of 16s rDNA. Ralstonia pickettii is a gram negative bacterium, capable of forming biofilm on metal surfaces. Postoperatively, the patient received intravenous antibiotic therapy with ciprofloxacin and cefepime, for 6 weeks, according to the results of the antibiogram. Due to fistula relapse after two surgical debridements, large bone defects and degeneration of the patellar tendon, knee arthodesis was performed.

In literature, there is only one reference of periprosthetic knee infection because of Ralstonia pickettii. Although quite rare, the periprosthetic knee infection caused by Ralstonia pickettii can be extremely durable with disastrous results for the knee joint.

In spite of its incidence decreasing to 1% nowadays, prosthesis-related infections remain a research, diagnostic, therapeutic and cost-related problem. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Our study aim was firstly to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of fluid derived from vortexing and bath sonication of the explanted hardware and secondly to investigate the role of possible metabolic factors affecting the sensitivity of the sonication method.

We investigated 70 patients undergoing revision hip or knee arthroplasty because of loosening of the prostheses, at our institution, between October 2011 and November 2013. Patients’ medical history and demographic characteristics were recorded. We compared the culture of samples obtained by sonication of explanted hip and knee prostheses with conventional culture of periprosthetic tissue for the microbiological diagnosis of prosthetic-joint infection.

Infectious Diseases Society of America (IDSA) Guidelines were used for the definition of prosthetic-joint infection. Thirty-two patients had septic loosening and 38 aseptic loosening (48 hip prostheses and 22 knee prostheses). The sensitivity of sonication fluid culture was 81.25% and the sensitivity of conventional tissue cultures was 56.25% (p-value = 0.043). The sensitivity of the sonication method was statistically higher in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis (p-values < 0.05).

The sonication method represents a reliable test for the diagnosis of prosthetic – joint infections with a greater sensitivity than the conventional periprosthetic tissue cultures, especially in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis.

Objective: we present the long-term behavior of polyethylene’s insert in acetabular implants ARC2F.

Materials and Methods: from 1989 to 1995, 668 THA’s were implanted. Mean patients age was 54 years (28–75). The preoperative diagnosis included: primary OA 501 cases, post-traumatic arthritis 24, hip dysplasia 112, AVN 31. In all cases Omnifit femoral stem with proximal HA coating and ARC2F acetabular component were used. 165 patients (182 arthroplasties) were lost to follow-up. The average time of observation was 15 years (13–18.5).

Results: all THA’s performed well without signs of wear at 10 years. No implant was revised during the first decade because of mechanical loosening. Since then, during the 13th – 14th year, a significant number of patients appeared with symptoms of polyethylene’s massive destruction and significant osteolysis at the femoral and acetabular side of the arthroplasty. We recalled all patients that could be found. Totally, 178 from 486 THA’s had similar radiographic signs of wear. Only 33 of all these had initial wrong orientation of the cup.

Conclusion: despite the excellent early and middle-term results, ARC2F shows rapid and massive wear of the insert after 12 years, probably because of degeneration and loss of polyethylene’s structural integrity due to the method of sterilization. We suggest to recall and inspect all the patients which have this kind of implant more than 12 years.

Objective: The presentation of mid-term results of porous tantalum TMT cup in congenital high hip dislocation.

Materials and Methods: Between November 1997 and December 2000, we performed 27 total hip replacements in 22 women patiens suffering from high congenital hip dislocation according Xartofilakidis classification. The acetabular component was implanted at the true acetabular bed with restoration of the centre of hip rotation. Clinical and radiological observation took place in regular intervals for an average time of 10.2 years (8.5–12 years).

Results: The average Harris Hip Score improved from 48.3 preoperatively (range 15–65) to 89.5 at the latest follow-up (56–100). Oxford hip score declined from 49.5 preoperatively to 21.2 at the first year and to 15.2 at five years examination. The absolute acetabular component’s migration was evaluated by EBRA method in the first 2 years and was at average 0.85 mm at the first year and 1.05 mm at the second year. An incident of gross initial migration was observed. No acetabular revision was performed and there was no case of mechanical loosening.

Conclusion: The acetabular TMT component is highly adhesive and porous with a modulus of elasticity close to subchondral bone. It promotes initial stability, induces bone penetration and integration and offers a more “physiologig” load transfer. It also offers adequate polyethylene thickness, even in the smallest sizes, due to its manufacturing. The recent results from its use in high hip dislocation are excellent and justify the further study of longevity and probably the superiority of this material.

One hundred and twenty-nine patients who had had 153 consecutive primary total knee replacements (twenty-four bilateral procedures) between February 1988 and February 1990, with insertion of medial pivot total knee system with cementless femoral and cementless tibial component without replacement of the patella, were enrolled in a prospective study. The average age of the patients at the time of surgery was 67.4 years, the average weight was 78 kg, and the most common diagnosis was osteoarthritis (prevalence, 92.9%). Twenty-six knees had a valgus deformity, ninrty-nine had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus Six patients had a previous high tibial osteotomy, twenty-one arthroscopic debridment and thirty-two total knee athroplasty at the other knee.

One hundred and ten patients (123 knees) were followed for an adequate interval (mean, 5.1 years; range, 3.8 to 6.8 years). Thirteen patients (fifteen knees) died, and twelve patients (fifteen knees) were lost to follow-up. The mean age of the patients at the time of the index arthroplasty was seventy years (range, twenty-nine to eighty-five years). The patients were evaluated clinically and radiographically, according to the scoring system of the Knee Society, and the results on a self-administered questionnaire were used to evaluate pain, function, satisfaction, and patellofemoral symptoms. A Kaplan-Meier survivorship analysis was performed with a revision operation as the end point. Failure was defined as aseptic loosening as evidenced by progressive radiolucent lines and/or revision due to aseptic loosening or collapse.

The mean functional and clinical scores, according to the system of the Knee Society, were 85 and 93 points, respectively, at the most recent follow-up examination. The result was excellent for 103 knees, good for thirteen, fair for three, and poor for six. One revision operation was necessary because of infection. The over-all rate of patellofemoral symptoms was 6 per cent (seven knees). Non-progressive radiolucent lines were present at the cement-bone interface in 39 per cent (thirty-nine) of the ninety-nine knees that had complete radiographic follow-up. No prosthesis had loosened by the time of the most recent follow-up examination. The rate of survival of the implant was 97 per cent at six years, and the standard error of the mean was 1.6 per cent.

In the present series, total knee arthroplasties with the medial pivot modular knee system resulted in excellent relief of pain, an excellent range of motion, and restoration of function. They were also associated with a low prevalence of patellofemoral problems.

Aim:We present our experience and the results of the treatment on 36 patients with fracture of the distal end of the clavicle (Grade II type 2) by open reduction of the fracture. Method: 25 men and 11 women were treated operatively for unstable (grade II, type 2) clavicular fracture from 1999 to 2002. The average age was 27.2 years (range, eighteen to thirty- þve years). The operations were performed under general anaesthesia. By the proper procedure the clavicle and the base of the coracoid was exposed. A 3.5mm hole was drilled, and a screw is introduced through the clavicle into the coracoid. The torn ends of the coracoclavicular ligaments are tagged with sutures. Six to nine weeks postoperatively the screw was removed. Results: All patients were reviewed radiologically and clinically after on average interval of 16 months. The healing of the fractures occurs about 8 weeks later. All patients were restored to the pre Ð injury level function with no pain or abnormal motion. Conclusions: Internal þxation with Boswarth screw and repair of the coracoclavicular ligament is an effective operation for Grade II type 2 unstable clavicular fractures specially for young and athletic patients

We present our experience with HA-coated total hip prosthesis in a minimum follow-up of eight years.

From 1989 to 1991 we performed 92 THRs in 83 patients. The mean age was 62 years (range 32–75). The preoperative diagnosis was: O.A. 68, AVN 12, CDH 8, and post-traumatic arthropathy 4. Pre-operative mean was HHS 43.

A posterior approach was used. The ARC 2F Cup, an HA coated spherical cup with thread around the equator, was used. Initial stabilisation is achieved by screwing the cup into the acetabulum. If necessary, a secondary fixation is enhanced by one or two bone screws to the ilium. The Omnifit stem is HA-coated in the proximal third and gives good immediate metaphysical fixation and optimal filling of the metaphysis. Three doses of Cefuroxime for prophylaxis and low molecular weight heparine were used in all cases. All patients had non-weight-bearing on the second postoperative day, partial weight-bearing in six weeks and full weight-bearing in 12 weeks.

Four patients were lost to follow-up. Mean H.H.S. was 91 in the first six months, 93 in the first year, and 95 in the second and third year. In the fifth year 97.93% were symptom-free in the first six months and 97% from the third to the fifth post-operative year. 3.7% of the patients complained of mild or moderate activity related to hip pain.

No patients suffered marked or disabling pain. Four patients complained of thigh pain six and eight months post-operatively. There were no major complications except for two superficial and two symptomatic deep vein thromboses. All patients returned to their prior activities within four to six months post-operatively. Radiographic evaluation of acetabular components revealed bone condensation in all three Charnley zones. We had no component migration or screw breakage. Calcar resorption was detected on the femoral side in seven patients. During the first post-operative year, AP radiographs of eleven patients indicated cortical hypertrophy in zones 3 and 5. There was no subsidence of the femoral stem.

We believe our results are encouraging although the follow-up period is short. We have had no revisions and the functional results are quite good. All patients are asymptomatic and satisfied with the result.

The capacity of the lumbar spine canal has direct relation to space-compromising conditions. Primary narrowing of the canal may produce no symptoms, but a slight reduction in capacity as a result of degenerative lesions, age, or disc bulging may result in symptomatic spinal canal stenosis. We studied the dimensions in the adult Greek population in order to find the variability factor in the capacity of the lumbar spinal canal.

The dimensions of the lumbar spinal canal were measured in 27 adult men and 42 adult women, all under the age of 50. MRI was used to measure four levels of the spine (L2 through L5). The AP and transverse diameters, as well as the cross section area, were measured at each level. Mean age (sd) of females was 34.8 (6.8) years. Mean age for males was 35.2 (7.3) and was comparable to women (P0.8). Mean age of a third group of 11 males over the age of 50 was 54.5 (2.6). All individuals included in the study were healthy and without any apparent degenerative changes in the lumbar spine or any symptoms related to it. Hotelling’s tests (Anderson, 1958), in terms of multivariate measurements of the spinal canal, were used to compare both genders and the two age levels. Tests for trends in the lumbar levels L2 through L5 were based on the exact binomial distribution for the number of cases exhibiting a complete trend from L2 to L5. The reported significance levels are adjusted for multiplicity of tests.

The relation of spinal width to lumbar levels is shown separately for the groups of males and females women under the age of 50 and for the group of males under over the age of 50. In all four lumbar levels, the group of men over 50 years old had a narrower spinal canal compared with men under 50 years old (2=0.005). This was particularly evident in levels L2 and L5 where the spinal canal for older men was narrower by factors of 15.5% and 13.1%, respectively. In the two gender groups of comparable age, spinal width was found to differ between men and women (2< 0.0001). In particular, the females had a wider spinal canal than males in levels L2, L3 and L4 and a narrower canal in level L5. Spinal width was found to exhibit a decreasing trend in lumbar levels L2 through L5. The evidence for this trend was strong for all three groups: females under the age of 50 (P< 0.0001), men under 50 (2< 0.005), and the older men (P< 0.0001). A similar trend was present for the anteroposterior diameter, as well as for the Transverse diameter. A numerical summary (mean, sd) of all spinal measurements is reported.

We believe this study to be an important one that provides useful information regarding the capacity of the lumbar spinal canal, thus helping the surgeon to properly evaluate the stenotic patient.