Introduction

Orthopaedic rehabilitation of adolescences and young adults with high dislocation of the femur is rather challenging. The role of palliative salvage procedures is controversial enough in the cohort of patients.

Background. Hip Hemiarthroplasty is one of the commonest orthopaedic operation done in UK with recent NHFD data from 2017 report showing that 43% of the 77000 patients who presented to hospital had hemiarthroplasty. Literature suggests dislocation rate of 0.8% – 6.1% for Hip Hemiarthroplasty. Dislocation of hemiarthroplasty may lead to significant morbidity and mortality. Aim. To investigate if acetabular dysplasia has a significant association with hemiarthroplasty dislocation. Methodology. Retrospective multicentre review. Review of radiographs of patients receiving a hip hemiarthroplasty for a hip fracture measuring Acetabular index (sharp angle) and Lateral Centre edge angle(CEA). A large acetabular index and lower value for the center-edge angle suggest acetabular dysplasia. Measurements were made for 20 patients with dislocation and 20 patients without dislocation. Statistical assessment of the results with unpaired t test was performed. Results. Mean acetabular angle for those with dislocation was 42.65 degrees versus 37.8 for those without dislocation giving a p value of 0.000861. Mean Center-edge angle of those with dislocation was 26.1 degrees versus 37 for those without dislocation giving a p value of 0.000019. Conclusion. This study showed that the hemiarthroplasty dislocation group had higher acetabular index and Lower Center-edge angle compared to the hemiarthroplasty group without dislocation clearly demonstrating that acetabular dysplasia is implicated in the aetiology of hip hemiarthroplasty dislocation. Hence careful review of the pre-op X-rays for dysplastic features would benefit in making a sound management plan

Abstract. Background. Dislocation of a hip hemiarthroplasty is a devastating complication with a high mortality rate in elderly patients. Previous studies have suggested a higher dislocation rate in patients with neuromuscular conditions. In this study, we have reviewed our larger cohort of patients to identify whether there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for femoral neck fractures. Patients and Methods. Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population is composed of four groups: patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with dementia. Results. A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe dementia with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p=0.02) while none of the other neuromuscular conditions were statistically significant. Conclusion. Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson's disease in comparison to other groups. No increase was apparent for those with dementia or weakness from a previous stroke

Introduction. Dislocation of an uncemented total hip replacement (THR) can cause damage to the femoral hear, when it passes through the rim of metal acetabular shell. This can lead to metal transfer on the surface of the head or chipping of bulk head material. Although dislocation is one of most common complications in total hip arthroplasty (THA), little is known if causes any further damage to the articulating surface of ceramic heads in long term observations. Aim of the study. To evaluate, if dislocations of THR with ceramic on polyethylene bearing causes structural damage to the articulating surface of the femoral head in a follow-up of minium 10 years. Materials and methods. MATERIAL. This study included four groups of third generation (CeramTec Biolox forte) ceramic femoral heads with a diameter of 28 mm:. 8 heads dislocated in the first year(managed nonsurgically) where implants functioned for at least 10 years. 9 heads removed within 12 months after implantation because of recurrent dislocations. 11 heads retrieved after a minimum of 10 years from hips where no dislocation occurred. 8 unused heads. METHODS. Surface topography of retrieved heads was evaluated using Scanning Electron Microscopy with Energy – Dispersive X-ray Spectroscopy; roughness measurements were performed in three directions (0, 45,90 degrees) over a distance of 1,5 mm using a contact profilometer. Results. On the dislocated heads dark stained scratches were present in the lower, non weight-bearing part; SEM studies demonstrated presence of multidirectional smear-like metal deposits (Fig 1) with a small number of chipped ceramic grains. EDS analysis of scratches indicated presence of Ti or Ti,Al,V - dependant on construction alloy of the acetabular component. There were no differences in morphology of scratched areas between heads removed within a few months after dislocation and components retrieved after at least 10 years. Interestingly SEM findings within the weight-bearing part of dislocated heads were identical within corresponding areas of femoral heads articulating for 10 or more years as well as unused components (Fig 2). In these areas we observed a small number of pinholes and scratches, which we believe resulted from machining and subsequent polishing. Roughness measurements were consistent with SEM findings (Table 1). Areas covered by metal deposits had a significantly higher roughness compared to undamaged area. We did not observe statistical differences between roughness of weight-bearing area in all examined groups. Conclusions. Our study indicates, that dislocation of femoral head in a uncemented total hip replacement with ceramic on polyethylene bearing results in contained damage in the area which contacted the metal acetabular shell. Dislocation does not affect the weight-bearing surface of the head, even in a long-term follow-up. This study was financed by a National Science Centre grant No. 2012/05/D/NZ5/01840

In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years.

The improvement of general mobility was marginal, but those who were community walkers benefited the most. Pre-operative radiological measurements have been modified post-operatively to use lateral margin of the neo-acetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% to 13.7% [p<0.0001]. The mean changes in CE angle and Sharp's angle were 72° (range 56°- 87°) [p<0.0001] and 12.3° (range 9°- 15.6°) [p< 0.0001] respectively. Radiological evidence of progressive arthritic change was seen in only one hip, in which only a partial reduction had been achieved, and there was early joint space narrowing in another. Heterotopic ossification was observed in one patient with athetoid quadriplegia who remained pain free. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

This combined procedure provides a stable hip with sustained pain relief for the adolescent and young adult presenting with pain.

Aim

To assess the survivorship of a tapered fluted Titanium monoblock stem in conjunction with subtrochanteric shortening for patients with High Dislocation performed at 2 centres.

Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz. A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed. There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure. This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Introduction. It has been postulated that the larger femoral head size may be associated with reduced risk of dislocation after total hip arthroplasty(THA). However, Dislocation after THA has a multifactorial etiology with variables such as femoral head size, type of cup, stem and surgical approach. Objectives. The objectives of this study is to evaluate the association between femoral head component head size, surgical approach, surgeon's experience and the rate of dislocation after THA. Methods. From 2004 to 2013, 4,423 primary THA with varying femoral head sizes were performed at our institution. The operative approaches were Mini-One approach in 3,140 arthroplasties, OCM approach in 753, Hardinge in 483, and 2-incision approach in 47. The femoral head diameters were 26-mm in 2,965 of the procedures, 28-mm in 797, 32-mm in 516, 36-mm in 133, and 38-mm in 12. We compared the dislocation rates differences in surgical approach and the diameter of the femoral head. Statistical analysis was used by Chi-square test. Results. Dislocation occurred in 32 hips (0.72%) of the 4,423 hips. The rate of the dislocation was 0.64% following Mini-One approaches, 1.06% following OCM approaches, and 0.83% following Hardinge approaches. There was no dislocation in 2-inciision approaches. There was no significant difference in rate of dislocation between Mini-One group (0.64%) and non-Mini-One group (0.94%) (p=0.34). There was no significant difference in rate of dislocation between OCM group (1.06%) and non-OCM group (0.65%) (p=0.23). There was no significant difference in rate of dislocation between Hardinge group (0.83%) and non Hardinge group (0.71%) (p=0.77). Dislocation occurred in 23 hips (0.78%) with a 26-mm femoral head and in 7 hips (0.88%) with a 28-mm femoral head and in 2 hips (0.39%) with a 32-mm head. No dislocation occurred with a 36-mm head and 38-mm head. There was no significant difference in rate of dislocation between 32-mm and over head group and below 32-mm head group (p=0.22). In 3,265 cases, 55mm and under diameter of the cups were used by four high volume surgeons who experienced above 500 cases of THA. No dislocation occurred in this 3,265 cases with a 32-mm and over head diameter. Conclusion. Dislocation rate was 0.72%. Although this rate was too low to be statistical significant differences between femoral head component head size, surgical approach and the rate of dislocation, No dislocation was occurred in 55mm and under diameter of the cups and 32-mm head and over cases with experienced surgeons

Several design principles were considered paramount when the surgical technique of performing total hip arthroplasty through an incision in the superior capsule without dislocation of the hip joint was developed. These design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ without dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intraoperative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Personal experience with more than 1950 THA using the superior capsulotomy technique over a 12-year period has demonstrated several observations: Dislocation rate of 0.15% (3 in 1950); Acute deep infection rate of 0% (0 in 1950); Universal applicability: used in 99.7% of primary THA; Lateral femoral cutaneous nerve palsy incidence: 0/1950; Femoral nerve palsy incidence: 0/1950; Transient peroneal palsy incidence: 2/1950; Length of stay (since 2010): 1.55 days; Discharge to home: 98%; 90-day cost (2/13 to 2/14) compared to other exposures in CMS patients in the same institution: $24,200 vs $30,100; Readmission costs (CMS 2/13 to 2/14) at 90 days: $0. Conclusion: Performing total hip arthroplasty without dislocation and with preservation of the abductors, posterior capsule and short external rotations has proven to have a low dislocation rate, a low infection rate, and wide applicability. CMS 12-month expenditure data documenting ZERO dollars spent on readmission for any reason within 90 days of surgery demonstrates the potential for simultaneously improving incomes and reducing cost, with particular benefit within the CMS BPCI and private bundled payment programs

Surgical treatment options for Femoroacetabular impingement (FAI) includes both surgical dislocation and hip arthroscopy techniques. The primary aim of this study was to evaluate and compare the survivorship of arthroscopies (scope) and surgical dislocations (SD) at minimum 5-year follow-up. The secondary aim was to describe differences in functional outcomes between the 2 groups. This was a retrospective, single surgeon, consecutive, case-series from a large tertiary care centre. We evaluated all surgeries that were performed between 2005 and 2011. Our institutional database was queried for any patient undergoing surgery for FAI (pincer (n=23), cam (n=306), or mixed (n=103) types). Patients with childhood pathologies i.e. Legg Calve Perthes and slipped capital femoral epiphysis were excluded. This resulted in 221 hips (169 males, 52 females) who underwent either SD (94, 42.5%) or scope (127, 57.5%). A manual chart review was completed to identify patients who sustained a complication, underwent revision surgery or progressed to a total hip arthroplasty (THA). In addition, we reviewed prospectively collected patient reported outcome measure (PROMs) using (SF12, HOOS, and UCLA). Survivorship outcome was described for the whole cohort and compared between the 2 surgical groups. PROMs between groups were compared using The Mann-Whitney U test and the survival between groups was assessed using the Kaplan-Meier Analysis and the Log-Rank Mantel Cox test. All analyses were performed in SPSS (IBM, v. 26.0). The cohort included 110 SDs and 320 arthroscopies. The mean age of the whole cohort was 34±10; patients in the SD group (32±9) were younger compared to the arthroscopy group (39±10) (p<0.0001). There were 16 post-operative complications (similar between groups) and 77 re-operations (more common in the SD group (n=49) due to symptomatic metal work (n=34)). The overall 10-year survival was 91±3%. Survivorship was superior in the arthroscopy group at both 5- (96% (95%CI: 93 – 100)) and 8- years 94% (95%CI: 90 – 99%) compared to the SD Group (5-yr: 90% (95%CI: 83 – 98); 8-yr: 84% (95%CI:75 – 93)) (p=0.003) (Figure 1). On average HOOS improved from 54±19 to 68±22 and WOMAC from 65±22 to 75±22. The improvement in PROMs were similar between the 2 groups. We report very good long-term joint preservation for the treatment of FAI, which is similar to those reported in hip dysplasia. In addition, we report satisfactory improvement in function following such treatment. The differences reported in joint survival likely reflect selection biases from the treating surgeon; more complex cases and those associated with more complex anatomy were more likely to have been offered a SD in order to address the pathology with greater ease and hence the inferior joint preservation identified in this group. For any figures or tables, please contact the authors directly

Economic data, clinical outcome studies, and anatomical studies continue to support the Superior Hip Approach as a preferred approach for improved safety, maximal tissue preservation, rapid recovery, and minimised cost. Clinical studies show exceedingly low rates of all major complications including femur fracture, dislocation, and nerve injury. Economic data from Q1 2013 to Q2 2016 demonstrate that CMS-insured patients treated by the Superior Hip Approach have the lowest cost of all patients treated in Massachusetts by an average of more than $7,000 over 90 days. The data show that the patients treated by the Superior Hip Approach have lower cost than any other surgical technique. Matched-pair bioskills dissections demonstrate far better preservation of the hip joint capsule and short external rotators than the anterior approach. Design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ prior to femoral neck osteotomy; Excision of the femoral head, thereby avoiding surgical dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intra-operative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Conclusion. In contrast to the results of the Superior Approach, the anterior approach continues to show difficulties with wound problems, infection, intra- and post-operative fracture, and failure of femoral component osseointegration and even dislocation. Evidence continues to demonstrate that the Superior Hip Approach has advantages over all other surgical approaches to the hip

This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip. The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle. The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym. The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living. The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred. This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip

We reported a case of the acetabular depression fracture in conjunction with a central fracture dislocation of the hip that was treated with a unique surgical technique. CASE REPORT:. A 76-year-old man suffered a left acetabular fracture with severe left hip joint pain and walking disability. Acetabular fracture was not apparent on the initial radiographs including anteroposterior and oblique views of the pelvis. However, computed tomography (CT) scanning showed displaced acetabular depression fracture (a third fracture fragment) in the center of the weight-bearing area with fracture of the ilium and spontaneous reposition of central dislocation of the hip (Fig. 1, 2). It seemed that this fracture fragment created incongruity of the acetabular articular surface and the potential for hip joint instability. Therefore, the patient was treated with open reduction and internal fixation. SURGICAL TECHNIQUE:. To perform the procedure, the patient was placed in the lateral decubitus position. A direct lateral approach to the hip was used for exposure. The vastus lateralis was released 1 cm distal from its origin, trochanteric osteotomy was done by the Gigli saw. To observe the hip articular surface and to identify the fracture fragment, the femoral head was posterior dislocated with excision of teres ligamentum after T-shaped capsulotomy. The depressed fragment in the acetabulum was identified under direct vision but could not be reduced. Therefore, the outer cortex of the ilium was fenestrated in a size of 2 × 2 cm so that a 1-cm-wide levator was inserted to the depressed fragment at 2 cm proximal from the hip articular surface through the fenestrated window (Fig. 3). Subsequently, the displaced bone fragment was pushed down by using the levator to the adequate articular joint level. The fragment was stabilized with packed cancellous bone graft harvested from the osteotomized greater trochanter. The removed outer cortex of the ilium from fenestrated site was repositioned and fixed by a reconstruction plate and screws. The osteotomized greater trochanter was reattached and fixed with two cannulated cancellous hip screws. RESULTS:. At 9-month follow-up, he was pain-free and continued to function well without the use of external supports. The acetabular depression fracture was completely reduced and healed in the CT scanning evaluation. The patient had no signs of posttraumatic osteoarthritis in radiographs. DISCUSSION and CONCLUSION:. In acetabular fracture dislocations of the hip joint, the precise pathological anatomy is not easily demonstrated by routine radiographs with classification of acetabular fractures. In our case, however, details of acetabular fracture were not well visible on conventional radiographs. It has been shown that computed tomography is useful method in precise evaluation of the fracture type with bone damage and integrity of joint configuration. Concerning approach to the fracture fragment which existed in the center of the weight bearing area of acetabulum, we performed to fenestrate on the intact bony cortex of the ilium just proximal to the fracture site. It was convenient and useful to gain good reduction of the central acetabular depression fracture, although there was no report on such a ‘fenestration’ method

Patients with neuromuscular disease and imbalance present a particularly challenging clinical situation for the orthopaedic hip surgeon. The cause of the neuromuscular imbalance may be intrinsic or extrinsic. Intrinsic disorders include those in which the hip is in development, such as cerebral palsy, polio, CVA, and other spinal cord injuries and disease. This can result in subluxation and dislocation of the hip in growing children, and subsequent pain, and difficulty in sitting and perineal care. Extrinsic factors involve previously stable hips and play a secondary role in the development of osteoarthritis and contractures in later life. Examples of extrinsic factors are Parkinson's disease, dyskinesis, athetosis, and multiple sclerosis. Goals of treatment in adults with pain and dysfunction in the setting of neuromuscular imbalance are to treat contractures and to perform salvage procedures to improve function and eliminate pain. Treatment of patients with neuromuscular imbalance may include resection arthroplasty (Girdlestone), arthrodesis, or total hip arthroplasty. Resection arthroplasty is typically reserved for patients that are non-ambulatory, or hips that are felt to be so unstable that arthroplasty would definitely fail due to instability. In modern times arthrodesis has limited use as it negatively impacts function and self-care in patients with neuromuscular disorders. Total hip arthroplasty has the ability to treat pain, relieve contractures, and provide improved function. Due to the increased risk of instability, special considerations must be made during primary total hip arthroplasty in this patient cohort. Risk of instability may be addressed by surgical approach, head size, or use of alternative bearing constructs. Posterior approach may have increased risk of posterior dislocation in this patient group, particularly if a posterior capsular repair is not possible due to the flexion contractures and sitting position in many patients. Surgeons familiar with the approaches may utilise the anterolateral or direct anterior approach judicially. Release of the adductors may be performed in conjunction with primary total hip arthroplasty to help with post-operative range of motion and to decrease risk of instability. In a standard bearing, the selected head size should be the largest that can be utilised for the particular cup size. Rigorous testing of intra-operative impingement, component rotation, and instability is required. If instability cannot be adequately addressed by a standard bearing, the next option is a dual mobility bearing. Multiple studies have shown improved stability with the use of these bearings, but they are also at risk for instability, intraprosthetic dislocation, and fretting and corrosion of the modular connections. Another option is a constrained liner. However, this results in reduced range of motion, and an increased risk for mechanical complications of the construct. The use of a constrained liner in a primary situation should be limited to the most severe instability cases, and the patient should be counseled with the associated risks. If total hip arthroplasty results in repeated instability, revision surgery or Girdlestone arthroplasty may be considered

Fully constrained liners are used to treat recurrent dislocations or patients at high risk after total hip replacements. However, they can cause significant morbidities including recurrent dislocations, infections, aseptic loosening and fractures. We examine long term results of 111 patients with tripolar constrained components to assess their redislocation and failure rate. The purpose of this study was to assess survivorship, complications and functional outcomes at a minimum 10 years after the constrained tripolar liners used in our institute. We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1998 and 2008. Eighty-nine were revised due to recurrent dislocations, 11 for pseudotumor with dysfunctional abductors, and 13 for periprosthetic infection with loss of soft tissue stabilizers. All patients had revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 had more than 3 revisions. We extracted demographics, implant data, rate of dislocations and incidence of other complications. Kaplan Meier curves were used to assess dislocation and failure for any reason. WOMAC was used to assess quality of life. At 10 years, the survival free of dislocation was 95.6% (95%CI 90- 98), and at 20 years to 90.6% (95% CI 81- 95.5). Eight patients (7.1%) had dislocations of their constrained liners: 1 patient had simultaneous periprosthetic infection identified at the time of open reduction, and 1 patient sustained stem fracture 3 months prior to the liner dislocation. At 10 years, the survival to any further surgery was 89.4% (95% CI 82–93.8), and at 20 years, this was 82.5 (95% CI 71.9–89.3). Five patients (4.4%) had deep infection: 4 of these had excision arthroplasty due to failure to control infection, while 1 patient was treated successfully with debridement, exchange of mobile components and intravenous antibiotics. Two patients (1.8%) had dissociated rings that required change of liner, ring and head. Two patients (1.8%) had periprosthetic femoral fractures that were treated by revision stems and exchange of constrained liners. The mean WOMAC functional and pain scores were 66.2 and 75.9 of 100, respectively. Constrained tripolar liners in our institute provided favourable results in the long term for recurrent dislocation hip arthroplasty with dysfunctional hip stabilizers. Infection in these patients can prove to be difficult to treat due to their poor soft tissue conditions from repeated surgeries. Comparing long terms results from other types of constrained liners is essential to evaluate these salvage liners

Introduction. Total hip arthroplasty (THA) is the most common surgery performed for complications of bipolar arthroplasty. The present study evaluated the functional results and complications associated with this surgery. Patients and Methods. Forty eight hips (48 patients) who had conversion of bipolar arthroplasty to THA between 1998 June and 2013 June, and who were followed-up for more than one year were evaluated. Twenty one hips had conversion surgery to THA using a Fitmore cup with metal-on-metal articulation (28 mm head). Six hips had surgery using the SecurFit cup and three hips, using the Lima LTO cup with ceramic-on-ceramic articulation (28 mm or 32 mm head). Eighteen hips had surgery using a large head metal-on-metal bearing: –MMC (seven hips), ACCIS (six hips) and Magnum (five hips). The average time of follow-up duration was 3.9 years (range, 1.0–11.3). There were 22 men and 26 women between the ages of 28 and 80 years (average, 68.9 years) at the time of conversion surgery. Conversion arthroplasty was performed for acetabular erosion without femoral stem loosening in 19 hips, acetabular cartilage erosion with femoral stem loosening in 13 hips, periprosthetic fracture in 12 hips, and recurrent dislocation in four hips. Results were evaluated using Harris hip score (HHS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) score. The radiographs were analyzed for evidence of acetabular and femoral osteolysis or loosening. The complications were evaluated. Results. The time interval between hemiarthroplasty and conversion total hip prosthesis was 6.7 years on average (range, 5 months to 12 years). Pain was the leading sign in all patients. Average HHS improved from 42 preoperatively (range, 34–67) to 86 (range, 65 – 97) postoperatively. The average total WOMAC score improved from 47 (range, 32–67) to 22 (range, 9–44) postoperatively. All the patients operated for groin pain reported significant improvement in their symptoms. Radiological evaluation showed good bony ingrowth and stability of all the femoral components. None of the acetabular component showed migration, loosening, wear, or osteolysis at last follow-up. Complications occurred in five hips. One dislocation and one recurrent dislocation were encountered in isolated acetabular revision hips; whereas one single dislocation, one recurrent dislocation, and one trochanteric nonunion occurred in the hips with revision of both components. All dislocations were occurred in hips with a femoral head size of 28 mm. Dislocations were managed by closed reduction, and none of the patients required revision for dislocation. Conclusions. Conversion THA after symptomatic bipolar arthroplasty can offer reliable pain relief and functional improvement. The perioperative complications approximate those of revision THAs

Background. Well-fixed cementless stems are sometimes needed to be extracted in patients with complications including periprosthetic infection, stem-neck breakage or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing re-implantation surgery following removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure(Fig.1, Fig.2). Methods. We conducted a retrospective study and radiographic review of 16 patients who had undergone re-implantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage or trunnionosis. The study group consisted of 2 men and 14women with an average age of 68.4 years. Mean follow-up was 33.1± 25.0 months. Operation time, intraoperative bleeding, complications, causes of re-operation and clinical score were evaluated and the Kaplan-Meier method was used to evaluate the longevity of the stem. Results. The average operation time was 272±63 minutes and intraoperative bleeding was 420±170 ml. Although postoperative dislocation occurred in 5 hips and sinking of the stem was found in 3 hips after surgery, no progression of the stem sinking was observed and the clinical JOA and JHEQ scores were both improved after re-implantation surgery. Re-implantation surgery with Zweymüller-type stems, which are shorter than those removed, revealed evidence of osseointegration of the stem without femoral fracture. Kaplan-Meier survival analysis of stem revision for any reason as the end point revealed 70.3% survival at 9 years (Fig.3). Conclusion. The FLS procedure is expected to confer successful clinical results without loosening of the stem, following safe extraction of well-fixed porous-coated cementless stems without fracture and will allow re-implantation with shorter cementless stems than those removed. For any figures or tables, please contact the authors directly

Over the past fifteen years hip preservation surgery has rapidly evolved. Improved understanding of the pathomechanics and associated intra-articular degeneration of both hip instability and femoroacetabular impingement have led to improved surgical indications, refined surgical techniques and more effective joint preservation surgical procedures. The periacetabular osteotomy (PAO) was initially introduced by Ganz and colleagues and has become the preferred treatment in North America for pre-arthritic, symptomatic acetabular dysplasia. Both hip arthroscopy and safe surgical dislocation of the hip have been popularised for the treatment of symptomatic femoroacetabular impingement disorders. Hip arthroscopy is effective for focal and\or accessible impingement lesions while the surgical dislocation approach is reserved for nonfocal disease patterns as seen in complex FAI, and residual Perthes and SCFE deformities. Femoroacetabular impingement from major acetabular retroversion can be managed with the PAO if there is coexistent posterosuperior acetabular insufficiency. Short- to mid-term results of these procedures are generally good to excellent for most patients and the complication rates associated with these procedures are very acceptable. Long-term outcomes are best known for the PAO. Several recent studies have documented survivorship rates of 65–90% at 10–20-year follow-up. Certain factors are associated with long-term success including minimal pre-operative radiographic OA, early symptoms, accurate acetabular correction, and younger age. These data strongly suggest that the PAO can defer THA to an older age for most patients while completely avoiding arthroplasty may only be possible in select patients with excellent congruency, no secondary OA and an ideal surgical correction

The parameters to be considered in the selection of a cartilage repair strategy are: the diameter of the chondral defect; the depth of the bone defect; the location of the defect (weight bearing); alignment. A chondral defect less than 3 cm in diameter can be managed by surface treatment such as microfracture, autologous chondrocyte transplantation, mosaicplasty, or periosteal grafting. An osteochondral defect less than 3 cm in diameter and less than 1 cm in depth can be managed by autologous chondrocyte transplantation, mosaicplasty or periosteal grafting. An osteochondral defect greater than 3 cm in diameter and 1 cm in depth is best managed by an osteochondral allograft. If there is an associated knee deformity, then an osteotomy should also be performed with all of the aforementioned procedures. In our series of osteochondral allografts for large post-traumatic knee defects realignment osteotomy is performed about 60% of the time in order to off load the transplant. To correct varus we realign the proximal tibia with an opening wedge osteotomy. To correct valgus, we realign the distal femur with a closing wedge osteotomy. Our results with osteochondral allografts for the large osteochondral defects of the knee have been excellent in 85% of patients at an average follow-up of 10 years. The Kaplan-Meier survivorship at 15 years is 72%. At an average follow-up of 22 years in 58 patients with distal femoral osteochondral allograft, 13 have been revised (22%). The 15-year survivorship was 84%. The results for the hip are early. To date we have performed this procedure on 16 patients. Surgical dislocation of the hip is carried out via a trochanteric osteotomy and the defect defined and trephined out. A press-fit fresh osteochondral allograft is inserted using the trephine technique. We have published our early results on a series of 8 patients with 5 good to excellent results, 1 fair result and 2 failures