Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes. We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations. 13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery. With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations

Introduction. Cephalomedullary nailing (CMN) is commonly used for unstable pertrochanteric fracture. CMN is relatively safe method although various complications can potentially occur needing revision surgery. Commonly used salvage procedures such as renailing, hemiarthroplasty, conservative treatment or total hip arthroplasty (THA) are viable alternatives. The aim was to investigate the rate of THA after CMN and evaluate the performance on conversion total hip arthroplasty (cTHA) after failure of CMN. Method. Collected data included patients from two orthopedic centers. Data consisted of all cTHAs after CMN between 2014-2020 and primary cementless THA operations between 2013-2023. Primary THA operations were treated as a control group where Oxford Hip Score (OHS) was the main compared variable. Result. From 2398 proximal femoral hip procedures 1667 CMN procedures were included. Altogether 46/1667 (2.8%) CMNs later received THA. Indications for THA after CMN failure were 13 (28.3%) cut-outs, nine (19.6%) cut-throughs, eight (17.4%) nail breakages, seven (15.2%) post traumatic arthrosis, seven (15.2%) nonunions, one (2.2%) malunion and one (2.2%) collum screw withdrawal. Mean (SD) time to complication after CMN operation is 5.9 (6.8) months. Mean (SD) time from nail procedure to THA was 10.4 (12.0) months. Total complication rate for cTHA after CMN was 17.4%. Reported complications were infection with seven (15.2%) cases and one (2.2%) nerve damage. Mean (SD) time to cTHA complication was 3.6 (6.1) months. One-sample T-test showed OHS to be significantly better (P<.001) for primary cementless THA compared to cTHA after one year. Conclusion. Altogether 2.8% of CMN were converted to THA. Nearly half (47.8%) of the cTHA procedures were due to CMN cut-out or cut-through. OHS was significantly better in primary cementless THA compared to cTHA. Prosthetic joint infection was the most frequent complication related to cTHA

Repeat revision hip replacements can lead to severe bone loss necessitating salvage procedures such as proximal or total femoral replacement. We present medium term outcomes from our experience of the Limb Preservation System (LPS) in patients with failed revision hip arthroplasties. All patients undergoing proximal femoral or total femoral replacement from 2003–2007 at our unit were reviewed. Data was collected preoperatively and at annual assessment post procedure for a minimum of 5 years. This included clinical review, functional outcome scores (WOMAC, Oxford Hip Score, Harris Hip Score) and radiographic evaluation. A total of 17 patients underwent femoral replacement (13 proximal, 4 total) using the LPS during the study period. Within this cohort there were 13 males and 4 females with a mean age of 64 years (range 47–86). Median follow up was 7 years (range 5–9 years). Primary diagnoses were DDH (7), Primary OA (5), RA (2), proximal femoral fracture (2) and phocomelia (1). Five patients (29%) required further revision surgery for infection (2 patients) or recurrent dislocations (3 patients). No stems required revision due to aseptic loosening or stem failure at 5–9 years. Compared to preoperative assessment, there was significant improvement in median outcome scores at 5 years (WOMAC increased by 33 points, Oxford hip score by16 points and Harris hip score by 43 points). 82% of patients maintained functional independence at latest review. The Limb Preservation System offers a salvage procedure for failed revision total hip arthroplasty with significant symptom and functional improvement in most patients at medium term follow up

Currently, there are no generally accepted treatments for the prevention of osteonecrosis. To compound this further, despite considerable research efforts, the natural history of this disease remains poorly understood. The disease process appears to be initially asymptomatic, but after symptoms appear, the course becomes rapidly progressive. Clinical studies have shown that, if left untreated, collapse of the femoral head will occur in 80 per cent of the cases or greater within four years. As our knowledge of the etiology and pathogenesis of osteonecrosis improves, new treatments to halt, or at least impede, the progression of the disease may be possible. Achieving the best outcomes in the treatment of osteonecrosis depends on early, accurate diagnosis, and prompt treatment appropriate for the stage of the disease. In many cases, if treated early, long-term preservation of the native joint is possible. Magnetic resonance imaging allows accurate diagnosis in even the earliest asymptomatic stages of the disease. Non-surgical treatments such as pharmacological agents have shown promise in experimental studies, although further work remains before they are appropriate for widespread use. Various hip salvaging procedures such as core decompression, percutaneous drilling, non-vascularized and vascularized bone grafting, and various osteotomies have been successful in the majority of properly selected patients over follow-up times of a decade or more. Advances in arthroplasty technologies and techniques, including hip resurfacing and modern cementless total hip arthroplasty have allowed patients to return to pain-free, active lifestyles with excellent long-term prosthesis survival. Current treatments for osteonecrosis, while generally successful, focus on halting or delaying the progression of symptomatic disease. Recent discoveries concerning the relationship between genetic factors and the development of osteonecrosis, as well as the pathophysiologic effects of various indirect and direct risk factors such as corticosteroid use and sickle cell disease, continue to improve our understanding of the underlying disease process. While these discoveries are promising, we must continue to work towards the goal of being able to identify and treat the precursors of osteonecrosis before it progresses to symptomatic disease and threatens the survival of native joints