Introduction: Femoroacetabular impingement (FAI) has been recently recognized as the main cause of hip pain in sportsmen. We analyse if clinical and functional results of surgical treatment are influenced by preoperative degenerative hip changes.

Materials and Methods: A series of 117 consecutive Ribas mini open procedures (mini open femoroacetabular osteoplasty with labral refixation) were performed in 115 sportsmen with confirmed clinical, radiographic, and MR-arthrography diagnosis of FAI, and were evaluated with a minimum follow up of 4 years (range: 4 – 6,5). According to Tönnis Grade for preoperative radiological degenerative hip stage, the hips were divided into 3 groups: group A/Tönnis 0: 32 hips; group B/Tönnis 1: 61 hips; group C/Tönnis 2: 24 hips. A Combined Clinical Score (CCS), which includes Impingement test, Merle D’Aubigné and WOMAC scores, was used to evaluate the patients before surgery and at 6 weeks, 3 months, 6 months and every year after operation. Satisfactory and unsatisfactory results were obtained and collected. SPSS 10.0 software (SPSS INC, Chicago, Ill) was used for statistical analysis and comparisons were performed by means of chi-squared and Wilcoxon tests; p< 0,05 was considered to be significant.

Results: With CCS method, satisfactory results were obtained in group A (Tönnis 0) in 93,4% of the cases at 12 months, in 96,5% at 24 months, and in 97,8% at the latest follow up of 48 months; in group B (Tönnis 1) satisfactory results were observed in 91,3% of the cases at 12 months, in 91,2% at 24 months, and in 93,6% at 48 months; in group C (Tönnis 2) satisfactory results were obtained in 58,3% of the cases at 12 months, in 55,3% at 24 months, and in 50,1% at 48 months. Differences between groups A and C, as like between groups B and C, were significant (p< 0,001), but not between groups A and B (p> 0,05).

Conclusions: Midterm results of the Ribas mini open procedure for the treatment of femoroacetabular impingement are encouraging, expecially in hips not exceeding Tönnis Grade 1 osteoarthrosis, as results depend directly on degenerative state. If symptomatic patients are treated in early stages, excellent expectancies can be obtained with this procedure already at midterm. In addition, instruction of general physicians and specialists in the diagnosis of FAI is of paramount importance.

Introduction: Higher loosening rate, improvements in metalo n metal bearings and excellent immediate clinico-functional results related with current Standard total hip endoprosthesis, have suposed the rennaisance of the new hip resurfacing implants. In this work we present our experience the first 486 cases and minimal 5 years follow up.

Material and method: From July 2003 to December 2008 486 surface arthroplasties were implanted in our institution (4 bilateral) in 450 patients, 314 males y 136 females, mean age of 46,6 years (16 – 69). 9 BHR, 2 ASR, 3 ADEPT, 5 CORIN, 22 Mitch and 409 CONSERVE PLUS models were implanted. In 454 cases a modified Kocher-Langenbeck posterior approach and in 32 cases Hueter’s anterior approach were carried out. Surgical time, intraoperative bleeding and collected blood in drains, components orientation in AP radiographies, registered complications, Merle d’Aubigné, WOMAC and HHS clínico-funtcional scores were assessed. Statistical analysis was performed by means of chi-squared test and non – parametric tests.

Results: Mean surgical time was 1h 50’ (1h 15’ a 2h 30’), mean intraoperative bleeding 273,4 cc (210 – 360cc), drained blood 224,2 cc (180 – 380cc). During the first year 11 autodonated blood units were retransfused (during the first 5 months patients were encouraged for 1000cc. autodonation). Mean CCD angle was 139,7° (SD 130 – 147) and acetabular inclination 43° (SD 40 – 65°). There were 4 instances of femoral fractures during the first half year after surgery, which required conversiòn to a BFH total endoprosthesis, one too adducted cup (65°), which required only cup exchange. There was a very significant improvement in clinico-functional scores: MDA score improved from 12,9 pts. preoperative (11 – 14) to 17,4 at latest follow-up (15 – 18) (p< 0,001), WOMAC from 46,2 (19 – 67) to 93,2 (79 – 100) (p< 0,001) and HHS from 52,3 (range 42 – 60) to 96,7 (range 89 – 98) (p< 0,001). Main complications were 1 arterial femoral thrombosis, 1 deep venous thrombosis, 1 deep infection that required 2-stages exchange, 4 transient femoral pare-sia. Overall survivorship was 98,97%.

Conclusions: hip resurfacing implantation, when recommendations made by the first authors of these new models are properly carried out, provide excellent clinical-functional results, comparable to non cemented total hip implants, if not better. Longer follow up are required to assess more adequately these implants, although it will not probably mean in the majority of the cases any hip exchange of a standard THA in terms of morbidity and mid-longterm clinical-functional result. This assumption has been taken from our cases converted to a THA with BFH. For this reason we do think absolutely we dispose today a very promising implant for young adults with well stablished hip osteoarthritis.

Introduction: Surgical treatment of femoroacetabular impingement (FAI) is becoming a worldwide current practice. We analyse if clinical and functional results are influenced by preoperative degenerative hip changes.

Materials and Methods: 107 FAI operated hips in 105 patients with a mean follow up of 3,1 years (range: 31 to 53 months) were evaluated and divided into 3 groups according to Tönnis Scala for preoperative radiological degenerative hip stages: group A 32 patients Tönnis 0, group B 61 Tönnis 1 and group C 24 Tönnis 2. Impingement test, Merle D’aubigné and WOMAC scores were assessed 6 weeks, 3 months, 6 months and every year after operation. SPSS 10.0 software used (SPSS INC, Chicago, Ill) was used for statistical analysis and comparisons were performed by means of chi-squared test; p< 0,05 was considered to be significant.

Results: After 3 months impingement test improved significantly in 30 cases Tönnis 0 (93,75%; p=0,012) and 58 cases Tönnis 1 (95,08%; p=0,008), whereas in Tönnis 2 it was observed only in 14 cases (58,3%; p=0,354). At this point no statistical difference was observed at the subsequent three years (p=0,273, p=0,377, p=0,334). Merle D’Aubigné and WOMAC scores improved significantly at the latest follow-up in groups A (91,3%, p=0,010) and B (93,4,%, p=0,024). However in group C only 45,8% of the cases improved significantly (p=0,383).

Conclusions: Surgical results of FAI differ in patients with Tönnis stage 0 and 1 when compared with Tönnis 2. Thus it seems to be reasonable to recommend symptomatic patients surgical treatment of FAI as early as it appears.

Introduction: today there is still no consense in reconstruction of severe acetabular defects in hip revision. Since 1988 we use size matched impacted acetabulum allografts. We evaluate how they behave in the mid–and longterm.

Materials and Methods: we present our first 44 transplants with a mean follow-up of 12,2 years (range 7 to 18). The mean age of the patients was 58,6 years (range 19 to 83). According to Gross Classification 26 cases presented an acetabular defect type III while 18 presented type IV. Evaluation included Merle D’Aubigne Score and radiological assessment of allograft and cup according to Engh Criteria (JBJS, 1994).

Results: homogenization of the radiological trabecular pattern was observed in 42 from 44 cases (95,4%). There were 3 infections and 7 cases of aseptic loosening (15,9%), that were revised with new cup implantation. Up to now none of these 7 cases have shown further signs of loosening. According to the Kaplan-Meier’s curves the overall predictive survival rate was 76.4% at 15 years. In cases of pelvic discontinuity (type IV) survivorship was significantly higher (85,7%, p=0,018). There was a highly marked improvement in Merle D’Aubigne Score in Gait (2,2 preoperative – 4,9 at follow-up, p=0,021) and Pain (2,5 preoperative – 5,4 at follow-up, p=0,032).

Conclusions: despite published reports with high incidence of failures in the midterm with structural allografts this serie shows clearly that a size matched impacted acetabulum allograft can be successfull in severe defficiencies if proper donor selection and excellent fixation technique is undertaken.

Introduction and purpose: Femoroacetabular impingement (FAI) has become a well-recognized pathological condition over the last few years and different authors have published good results obtained after surgical treatment using osteoplasty. In this study we analyze the clinical and functional results seen in the first one hundred patients subjected to osteoplasty using a minimally invasive anterior approach.

Materials and methods: We analyzed the first 107 patients treated with a mean follow-up of 26 months (range: 6–41). They are assessed on a scale we drew up ourselves that takes into account the Impingement Test, the Merle D’Aubigné scale and the WOMAC score at 6 weeks, 3 months, 6 months and once a year. Results are classified according to these variables as excellent, good, fair and poor and are analyzed using the chi-square test (SPSS software, p< 0.05). Excellent and good results are considered satisfactory, the others are not.

Results: At 1 year satisfactory results are seen in 91.3 % of Tönnis 1 cases and 93.4% of Tönnis 0 cases; these results are maintained during the second year in 85.1% (p=0.375). On the other hand, in Tönnis 2 cases, only 55.3% good results are seen at 2 years. These differences were significant (p< 0.017).

Conclusions: Treatment of impingement by means of femoroacetabular osteoplasty using our minimally invasive approach results in a high proportion of satisfactory outcomes, especially during stages 0 and 1. However, such is not the case in stage Tönnis 2 cases. Therefore, it is advisable to use this procedure in symptomatic patients during the incipient stages of the condition.

Introduction: today there is still no consense in reconstruction of severe acetabular defects in hip revision. Since 1988 we use size matched impacted acetabulum allografts. We evaluate how they behave in the mid- and longterm.

Material and method: we present our first 44 transplants with a mean follow-up of 11,2 years (range 6 to 17). The mean age of the patients was 58,6 years (range 19 to 83). According to Gross Classification 26 cases presented an acetabular defect type III while 18 presented type IV. Evaluation included Merle D’Aubigne Score and radiological assessment of allograft and cup according to Engh Criteria (JBJS, 1994).

Results: homogenization of the radiological trabecular pattern was observed in 42 from 44 cases (95,4 %). There were 3 infections and 7 cases of aseptic loosening (15,9 %), that were revised with new cup implantation. Up to now none of these 7 cases have shown further signs of loosening. According to the Kaplan-Meier’s curves the overall predictive survival rate was 76.4 % at 15 years. In cases of pelvic discontinuity (type IV) survivorship was significantly higher (85,7%, p=0,018). There was a highly marked improvement in Merle D’Aubigne Score in Gait (2,2 preoperative – 4,9 at follow-up, p=0,021) and Pain (2,5 preoperative 5,4 at follow-up, p=0,032).

Conclusions: despite published reports with high incidence of failures in the midterm with structural allografts this serie shows clearly that a size matched impacted acetabulum allograft can be successfull in severe defficiencies if proper donor selection and excellent fixation technique is undertaken.

Purpose: To determine the incidence of anterior femoroacetabular impingement (AFAI) as a cause of idiopathic coxarthrosis in young adults.

Materials and methods: We carried out a retrospective study of 196 patients with total hip replacement (THR), selecting patients under 55 (51 cases, 26.02%). We recorded epidemiological, clinical and radiological data prior to the implantation of the THR. In all cases we used cementless stems and cups. The statistical analysis was done with SPSS software v10.0.

Results: The mean age was 50.7 (29–55). There was a predominance of men (31 cases, 61%) over women (20 cases, 39%). The mean BMI was 30.1 kg/m2 (20–42). The mean time with pain before hip arthroplasty was 8 years (2–20 years). Among the possible causes of the origin of coxarthrosis we found sequelae of acetabular fractures, hip growth dysplasias, rheumatoid arthritis, sequelae of Perthes disease and AFAI. 70.6% presented a “hump” in the head-neck junction on the axial projection, which appeared at the onset of symptoms; 10% presented frank deformity of the femoral head and 8% had protrusion of the head toward the acetabulum. The patients with AFAI presented less mean flexion (78.5°) and internal rotation (2.9°) (p< 0.05), and the predominant type of pain was inguinal irradiating to the thigh or greater trochanter (p< 0.05). The mean time from onset of symptoms to implantation of THR was less in this group (7.4 years) as compared to the rest (10.4 years) (p< 0.05).

Discussion: Murray (Br. J. Radiol 38:810–24, 1965) and Harris (CORR 213:20.23, 1986) had already mentioned AFAI as a predisposing factor in the degeneration of the coxofemoral joint. In recent years its importance has increased as the resection of the femoral hump in the initial degenerative stages has became more widespread (Tönnis 0 and I). This osteoplasty can be performed by hip arthroscopy (small humps), with dislocation of the femoral head (as described by R. Ganz) or by a very small anterior approach without dislocation of the femoral head as proposed by Ribas-Vilarubias (2004). Leunig (2005) speaks of an AFAI incidence of 15% in the general population and Tanzer (CORR 429:170-77, 2004) discovered “humps” in the femoral head-neck junction in 68–100% of patients with THR. Our study gives similar results, placing the incidence at 70.6% in patients under the age of 55 who have had a THR.

Conclusions: We think the incidence of femoroacetabular impingement is high and that this syndrome plays an important role in the onset of degeneration of the coxofemoral joint in young adults. These findings suggest the advisability of early surgery to attempt to delay the rapid progression toward primary arthroplasty at an early age.

Introduction: Femoroacetabular Impingement had been until now an unknown pathology. It causes pain in the movements of flexion-adduction-internal rotation, due to a bump effect between the head-neck surface of the femur and the anterior acetabular rim.

Material and Method: We analysed our 14 first patients, 3 operated bilaterally with 1 year F.U.. In bilateral cases, the time between both operations ranged from 5 to 8 weeks. Mean Age: 36 years (27 to 48), all sports active patients.. The technique that we used was through our modified Hueter approach . The superoanterior rim of the acetabulum was excised as well as the deformity at the femoral side that causes a less femoral neck-offset. For that purpose we used special maxilofacial-reamers instead of chisels. In this way we avoid any bleeding from the femoral neck. With this technique we avoid a Trochanter osteotomy, as performed by other authors (Ganz, Trousdale) .

Results: Pain relief was obtained 4 weeks after surgery in 13 from 14 patients. Mean hospitalization time was 2,6 days (2 to 5). Improvement in ROM was significative (p= 0,006): from −17 mean internal rotation (−14 to −28) at 80 flexion to +23 mean one month postop internal rotation (14 to 32).There was a significant improvement of hip score according to Merle d’Aubigne evaluation (p=0,017): 13,8 points preop (13 to 15) to 16,9 at F.U. (16–18). Neither Trendelemburg nor osteonecrosis was observed in any patient, as possible complications related to the approach. Mean time of rehabilitation was 3,8 weeks ( 3 to 5). All patients returned to their respective sports activities

Discussion: The Modified Femoroacetabular Osteoplasty allows rapid improvement of the normal hip motion , relatively short rehabilitation time and sports resumption as well. However midterm new osteoarthritic changes had to be assessed, although clinical and functional improvement has been evident. This surgical procedure makes us think about other alternatives to hip endoprosthesis in young adults.

Introduction: knee revision in absence of Extensor Mechanism has been always a challenging problem in Orthopaedics. Many authors are in favour to abandone any endoprosthetic substitution in front of such a situation.

We think osteotendinous allografts, in this particular case whole Extensor Mechanism allografts, could play an essential role before any Knee Arthrodesis.

Material and Method: From 1999 up to 2004 11 patients (4 male, 7 female) (mean age 72, range 68 to 86) underwent to a whole Extensor Mechanism allografting procedure. Mean follow up was 2.7 years (1 to 5 years).

In the first four cases a whole Extensor Mechanism allograft was implanted, while the next seven cases the allograft was reinforced by means of a Leeds-Keio Dacron band.

Results: There was no infections in this serie. The mean obtained R.O.M. in the first three months was – 5 of active extension (range 0 to −15) and 95 active flexion (range 80 – 110). However 3 from the 4 former operated cases had a progressive loss of active extension up to −25 (range −20 to −35) at 18 months, that did not increase after this period. Ultrasonic exams showed a lengthening of the patellar tendon in these cases. None of these 3 patients wished to undergo to a patellar tendon reinforcement.

On the other hand those later cases, where patellar tendon was reinforced did not show any change over the time (at 18 months mean active extension was maintained to −5 (range 0 to 15)

Conclusions: Extensor mechanism allografts are very useful in difficult knee revisions with absence of extensor mechanism, so that knee arthrodesis is not the method of choice for these patients. However augmentation of patellar tendon is necessary to maintain with the years an active extension.

Introduction: The anterior femoroacetabular impingement syndrome has so far been a great unknown in orthopedic surgery. It is typically characterized by pain when the hip is subjected to the flexion – adduction – internal rotation movement. This pain is provoked by the impaction of the head-neck interface on the anterior wall of the acetabulum. The reason for this may be a retroverted acetabulum, an excessively prominent anterosuperior femoral head-neck junction or a combination of both. For many years, patients have been diagnosed with “adductor tendinopathy” or “inguinal herniations”, when in fact they had a coxofemoral problem.

Materials and methods: The first 14 cases operated were analyzed; all of them were young patients who played sports regularly. Using the modified Smith-Petersen approach, an osteoplasty was made in order to resect in the anterior wall and the superior walls of the acetabulum – the latter only in part – and the prominent head-neck junction of the femur. The result was an improvement in the joint balance and the disappearance of impingement. Unlike other authors (Ganz, Trousdale), we avoided an osteotomy of the greater trochanter as a surgical approach.

Results: In 13 of the first 14 cases operated with the technique described, immediate pain relief was achieved on internal flexorotation. ROM went from −17 ° mean internal rotation (range: −14°–−28°) in one 80 ° flexion to +23° after one month postop (range: 14°–32°). After two months, there were no instances of Trendelemburg sign or osteonecrosis of the femoral head.

Conclusions: We should wait to assess the pre-osteoarthritic development of these patients, although their clinical and functional improvement is evident.

Introduction: Chiari osteotomy with capsuloplasty is an acetabulum-widening osteotomy which makes it possible to substantially correct dysplastic hips. This paper presents an overview of the results obtained after 25 years.

Materials and methods: Between 1983 and 2002, 127 Chiari osteotomies were carried out. 103 were revised (59 women, 40 men , 4 bilateral). Mean follow up: 11.2 years (range: 1 to 20 years). The endpoints were: operative time, VCA angles, acetabular inclination, pre-post-follow up CE angle, Merle d’Aubigne score, preop and postop Ahlbach score.

Results: Operative time: 1h 42′ (range: 57′ – 3h 10′). Ahlbach I – 26, II – 59, III – 18, IV – 0. Associated operations: Femoral osteotomy 77, varus-derotation osteotomy 36, Reconversion 31, Trochanteric retensioning. M 69. Angles measurement: preop: CE 5° (−34°−25°), VCA 18° (7°–26°), Tönnis 56° (43°–61°). Postop: CE 34° (10°–55°), VCA 31° (26°–39°), Tönnis 40° (38°–44°). Mean increase in acetabular inclination:16°. Merle d’Aubigné: preop 14.3(7–17), Follow-up 16.2(12–18). Excellent-good results 89(86.4%), Fair-poor results 14(14.6%) 2 went on to THA; Mean osteotomy displacement 26 mms (18–39). Invariability Ahlbach changes: If preop I 24/26(92.3%), if preop II 42/59(71.2%), if preop III 5 /18 (27.7%). Survival rate: 81.76% after 10 years.

Discussion and conclusions: Long term results seem satisfactory, with a survival rate of 81.76% after 10 years. This is a technique of choice in dysplasias with a new cup and in non-congruent hips, generally associated to a femoral osteotomy (77/103). It is crucial to perform the preop planning using Pawels test.