Aims. The hypothesis of this study was that thigh circumference, distinct from body mass index (BMI), may be associated with the positioning of components when undertaking total hip arthroplasty (THA) using the direct anterior approach (DAA), and that an increased circumference might increase the technical difficulty. Patients and Methods. We performed a retrospective review of prospectively collected data involving 155 consecutive THAs among 148 patients undertaken using the DAA at an academic medical centre by a single fellowship-trained surgeon. Preoperatively, thigh circumference was measured at 10 cm, 20 cm, and 30 cm distal to the anterior superior iliac spine, in quartiles. Two blinded reviewers assessed the inclination and anteversion of the acetabular component, radiological leg-length discrepancy, and femoral offset. The radiological outcomes were considered as continuous and binary outcome variables based on Lewinnek’s ‘safe zone’. Results. Similar trends were seen in all three thigh circumference groups. In multivariable analyses, patients in the largest 20 cm thigh circumference quartile (59 cm to 78 cm) had inclination angles that were a mean of 5.96° larger (95% confidence interval (CI) 2.99° to 8.93°; p < 0.001) and anteversion angles that were a mean of 2.92° larger (95% CI 0.47° to 5.37°; p = 0.020) than the smallest quartile. No significant differences were noted in leg-length discrepancy or offset. Conclusion. There was an associated increase in inclination and anteversion as thigh circumference increased, with no change in the risk of malpositioning the components. THA can be performed using the DAA in patients with large thigh circumference without the risk of malpositioning the acetabular component. Cite this article: Bone Joint J 2019;101-B:529–535

Aims. Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods. In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results. The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion. The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches. Cite this article: Bone Joint J 2023;105-B(12):1252–1258

We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated. A compartment syndrome of the thigh is a rare, but important complication of joint replacement surgery if patients are receiving anticoagulants. Close observation is needed and when indicated monitoring of the intracompartmental pressure should be done. Early recognition of the signs and symptoms of an acute compartment syndrome and knowledge of the anatomy of the compartments of the thigh will help in the diagnosis and treatment of this potentially devastating complication

Six porous-coated, uncemented femoral components were revised at a mean of 34.5 months for persistent thigh pain. At operation the stems were rigidly stable, difficult to extract, and showed good bony ingrowth. The four men and two women, with an average age of 59 years, all had thigh pain starting within the first year, progressive over time and unresponsive to conservative measures. These cases show that rigid fixation with good bony ingrowth does not guarantee the clinical success of a porous-coated uncemented femoral stem

A retrospective review of 148 consecutive porous-coated hip arthroplasties (PCA) showed an incidence of thigh pain of 13% one year after surgery, and 22% at two years. Positive correlations were made with femoral stem subsidence (greater than 2 mm) and with distal periosteal and endosteal bone formation. No positive correlations were made with parameters of bone quality or component fit. Resolution of pain occurred in one-third and an anti-inflammatory agent produced partial relief in two-thirds of the patients. We conclude that thigh pain is secondary to stem instability with distal stress transfer in the absence of stable proximal fixation

Aims

Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint.

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget’s disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain. There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain

Glomus tumours are rare and benign, arising from a neuromyoarterial glomus body, most commonly in the hand. We report a patient with such a tumour in an atypical site, the right vastus lateralis. Pain was aggravated by muscle contraction, and ultrasonography and MRI were required to locate the lesion accurately. Surgical excision gave immediate pain relief.

1. Ten patients are described in whom pain due to arterial obstruction simulated pain caused by bone or joint disease or by disorder of the intervertebral disc.

2. The importance is stressed of arterial obstruction at the aortic bifurcation or in the iliac vessels as a possible cause of pain in patients attending orthopaedic clinics.

Aims. The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique. Methods. This was a multicentre retrospective study involving consecutively enrolled patients who underwent L4-L5 LLIF by seven surgeons at seven institutions in three countries over a five-year period. The demographic details of the patients and the details of the surgery, reoperations and complications, including femoral and non-femoral neuropraxia, thigh pain, weakness of hip flexion, and abdominal complications, were analyzed. Neurological and psoas-related complications attributed to LLIF or posterior instrumentation and persistent symptoms were recorded at one year postoperatively. Results. A total of 517 patients were included in the study. Their mean age was 65.0 years (SD 10.3) and their mean BMI was 29.2 kg/m. 2. (SD 5.5). A mean of 1.2 levels (SD 0.6) were fused with LLIF, and a mean of 1.6 (SD 0.9) posterior levels were fused. Femoral neuropraxia occurred in six patients (1.2%), of which four (0.8%) were LLIF-related and two (0.4%) had persistent symptoms one year postoperatively. Non-femoral neuropraxia occurred in nine patients (1.8%), one (0.2%) was LLIF-related and five (1.0%) were persistent at one year. All LLIF-related neuropraxias resolved by one year. A total of 32 patients (6.2%) had thigh pain, 31 (6.0%) were LLIF-related and three (0.6%) were persistent at one year. Weakness of hip flexion occurred in 14 patients (2.7%), of which eight (1.6%) were LLIF-related and three (0.6%) were persistent at one year. No patients had bowel injury, three (0.6%) had an intraoperative vascular injury (not LLIF-related), and five (1.0%) had ileus. Reoperations occurred in five patients (1.0%) within 30 days, 37 (7.2%) within 90 days, and 41 (7.9%) within one year postoperatively. Conclusion. LLIF involving the L4-L5 disc level has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique. Cite this article: Bone Joint J 2024;106-B(1):53–61

Aims. Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Methods. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. Results. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. Conclusion. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160–1167

We compared the clinical and radiological outcomes of two cementless femoral stems in the treatment of patients with a Garden III or IV fracture of the femoral neck. A total of 70 patients (70 hips) in each group were enrolled into a prospective randomised study. One group received a short anatomical cementless stem and the other received a conventional cementless stem. Their mean age was 74.9 years (50 to 94) and 76.0 years (55 to 96), respectively (p = 0.328). The mean follow-up was 4.1 years (2 to 5) and 4.8 years (2 to 6), respectively. Perfusion lung scans and high resolution chest CTs were performed to detect pulmonary microemboli. At final follow-up there were no statistically significant differences between the short anatomical and the conventional stems with regard to the mean Harris hip score (85.7 (66 to 100) versus 86.5 (55 to 100); p = 0.791), the mean Western Ontario and McMaster Universities Osteoarthritis Index (17 (6 to 34) versus 16 (5 to 35); p = 0.13) or the mean University of California, Los Angeles activity score (5 (3 to 6) versus 4 (3 to 6); p = 0.032). No patient with a short stem had thigh pain, but 11 patients (16%) with a conventional stem had thigh pain. No patients with a short stem had symptomatic pulmonary microemboli, but 11 patients with a conventional stem had pulmonary microemboli (symptomatic in three patients and asymptomatic in eight patients). One hip (1.4%) in the short stem group and eight (11.4%) in the conventional group had an intra-operative undisplaced fracture of the calcar. No component was revised for aseptic loosening in either group. One acetabular component in the short stem group and two acetabular components in the conventional stem group were revised for recurrent dislocation. Our study demonstrated that despite the poor bone quality in these elderly patients with a fracture of the femoral neck, osseo-integration was obtained in all hips in both groups. However, the incidence of thigh pain, pulmonary microemboli and peri-prosthetic fracture was significantly higher in the conventional stem group than in the short stem group

Aims. Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length. . Patients and Methods. This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year’s follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80). Results. A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, . sd. 12.9 vs 62.7 years, . sd. 9.7; p < 0.001) and had shorter follow-up (3.3 years, . sd. 1.3 vs 3.7 years, . sd. 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7). Conclusion. A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31–36

Aims. Short-stemmed femoral implants have been used for total hip arthroplasty (THA) in young and active patients to conserve bone, provide physiological loading, and reduce the incidence of thigh pain. Only short- to mid-term results have been presented and there have been concerns regarding component malalignment, incorrect sizing, and subsidence. This systematic review reports clinical and radiological outcomes, complications, revision rates, and implant survival in THA using short-stemmed femoral components. Materials and Methods. A literature review was performed using the EMBASE, Medline, and Cochrane databases. Strict inclusion and exclusion criteria were used to identify studies reporting clinical and radiological follow-up for short-stemmed hip arthroplasties. Results. A total of 28 studies were eligible for inclusion. This included 5322 hips in 4657 patients with a mean age of 59 years (13 to 94). The mean follow-up was 6.1 years (0.5 to 20). The mean Harris Hip Score improved from 46 (0 to 100) to 92 (39 to 100). The mean Oxford Hip Score improved from 25 (2 to 42.5) to 35 (12.4 to 48). The mean Western Ontario & McMaster Universities Osteoarthritis Index improved from 54 (2 to 95) to 22 (0 to 98). Components were aligned in a neutral coronal alignment in up to 90.9% of cases. A total of 15 studies reported component survivorship, which was 98.6% (92% to 100%) at a mean follow-up of 12.1 years. Conclusion. Short-stemmed femoral implants show similar improvement in clinical and radiological outcomes compared with conventional length implants. Only mid-term survivorship, however, is known. An abundance of short components have been developed and used commercially without staged clinical trials. Long-term survival is still unknown for many of these components. There remains tension between innovation and the moral duty to ensure that the introduction of new implants is controlled until safety and patient benefit are demonstrated. Implant innovation and subsequent use should be driven by proven clinical outcomes, rather than market and financial forces, and ethical practice must be ensured. Cite this article: Bone Joint J 2019;101-B:502–511

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.