Publications by authors named "Martin Buttaro"

70 Publications

Preliminary outcomes of the cementless UNITED hip system for primary total hip arthroplasty at a minimum 2-year follow-up.

Eur J Orthop Surg Traumatol 2021 Jun 12. Epub 2021 Jun 12.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, 4247 Potosí St., C1199ACK, Buenos Aires, Argentina.

Introduction: This study aimed to report the initial results of the cementless UNITED hip system in primary total hip arthroplasty (THA) with a minimum follow-up of 2 years.

Methods: We retrospectively studied a consecutive series of 203 cementless THAs in 180 patients operated between 2015-2017. We included 89 female and 91 male patients with a mean age of 67 (28 to 89) years. The mean follow-up was 40 (29 to 62) months. Clinical outcome scores and radiographs were measured. Survival was calculated defining failure as the need for any further femoral or acetabular revision, irrespective of the reason.

Results: No femoral component loosening was detected. One patient had a Vancouver-B1 intraoperative periprosthetic femoral fracture treated with implant retention and cerclage wires. Two acetabular components were revised for aseptic loosening. Three patients suffered an acute infection treated with debridement, antibiotics, and implant retention. The mean Merle d'Aubigné et Postel scores improved from 13 (4 to 16) points preoperatively to 17 (12 to 18) points at the latest follow-up (p < 0.001). At a mean time of 40 months of follow-up, the survival was 99% and 100% for the acetabular and the femoral components, respectively.

Conclusion: This cementless design showed excellent preliminary outcomes in terms of fixation and patient satisfaction, comparable to that of other well-known similar systems.
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http://dx.doi.org/10.1007/s00590-021-03038-5DOI Listing
June 2021

Are lateral view radiographs necessary to properly classify femoral neck fractures? Intra and interobserver analysis using Garden's classification system

Rev Fac Cien Med Univ Nac Cordoba 2021 03 29;78(1):41-44. Epub 2021 Mar 29.

Hospital Italiano de Buenos Aires.

Introduction: Femoral neck fractures have been historically diagnosed by anteroposterior (AP) and lateral (L) radiographic views. We analyzed the importance of the L view for management of femoral neck fractures, using the Garden's classification system.

Materials And Methods: Slides were elaborated with AP and L radiographic views of 100 patients with femoral neck fractures admitted to our emergency department. Three hip surgeons assessed independently AP views only and then AP and L views together using Garden's classification system.

Results: No statistically significant differences (Kruskal Wallis 0, p=1) were found while comparing categories among Garden's classification system, after assessing L views. There was an 81 % (p < 0.001) agreement of Garden category between AP and AP combined with L views. When analyzing patients with changing categories between displaced and non displaced after assessing L view images, we found a 5% (n=5, CI 95% 1-11%) of change. For comparing AP Garden with L view Garden, we used a quadratic weighted kappa method.

Conclusions: There is a high agreement in the Garden category when comparing AP with combined AP and L observations. Five patients would have received a different surgical treatment dependent on the hip surgeon who assessed the radiographs. This highlights the relevance of routinely L radiographs whenever a femoral neck fracture is suspected.
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March 2021

Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'.

Bone Joint J 2021 Jan;103-B(1):79-86

'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Aims: We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA).

Methods: We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed.

Results: There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years.

Conclusion: If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: 2021;103-B(1):79-86.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-0955.R1DOI Listing
January 2021

Hip preservation surgery and the acetabular fossa.

Bone Joint Res 2020 Dec;9(12):857-869

Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Canada.

As our understanding of hip function and disease improves, it is evident that the acetabular fossa has received little attention, despite it comprising over half of the acetabulum's surface area and showing the first signs of degeneration. The fossa's function is expected to be more than augmenting static stability with the ligamentum teres and being a templating landmark in arthroplasty. Indeed, the fossa, which is almost mature at 16 weeks of intrauterine development, plays a key role in hip development, enabling its nutrition through vascularization and synovial fluid, as well as the influx of chondrogenic stem/progenitor cells that build articular cartilage. The pulvinar, a fibrofatty tissue in the fossa, has the same developmental origin as the synovium and articular cartilage and is a biologically active area. Its unique anatomy allows for homogeneous distribution of the axial loads into the joint. It is composed of intra-articular adipose tissue (IAAT), which has adipocytes, fibroblasts, leucocytes, and abundant mast cells, which participate in the inflammatory cascade after an insult to the joint. Hence, the fossa and pulvinar should be considered in decision-making and surgical outcomes in hip preservation surgery, not only for their size, shape, and extent, but also for their biological capacity as a source of cytokines, immune cells, and chondrogenic stem cells. Cite this article: 2020;9(12):857-869.
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http://dx.doi.org/10.1302/2046-3758.912.BJR-2020-0254.R1DOI Listing
December 2020

Who Restores Hip Biomechanics More Effectively after a Femoral Neck Fracture? Comparison of Total Hip Arthroplasties Performed by Either Hip Surgeons or Orthopaedic Residents.

Arthroplast Today 2020 Dec 29;6(4):736-741. Epub 2020 Aug 29.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: This study aims to analyze the ability to restore hip biomechanics in patients who undergo total hip arthroplasty for displaced femoral neck fractures operated by either hip surgeons (HSs) or orthopaedic residents (ORs).

Methods: We retrospectively compared 95 patients treated by HSs (group A) with 110 patients treated by ORs (group B). Leg-length discrepancy, femoral offset (FO), center of rotation (COR), acetabular inclination, and acetabular anteversion were evaluated on postoperative radiographs using the healthy contralateral hip as control.

Results: The median leg-length discrepancy was 2 mm for both groups ( = .74). The leg length was increased in 54% of the HS group and 57% of the OR group ( = .13). The median FO difference of groups A and B were 7 mm and 5.5 mm, respectively ( = .14). FO was increased in 80% of the HS group and 69% of the OR group ( = .19). Median discrepancies of the horizontal and vertical CORs were not statistically relevant, with -values of .69 and .14, respectively. The horizontal COR was slightly medialized in 58% of the HS group and 53% of the OR group ( = .003). The vertical COR was slightly proximal in 66% of the HS group and 76% of the OR group ( = .28). The median acetabular inclination angles of groups A and B were 41° and 40°, respectively ( = .62). The median anteversion angle was 19° for both groups ( = .89).

Conclusions: The horizontal COR was the only measurement with statistical significance. To conclude, ORs under supervision are as reliable as HSs to properly restore hip biomechanics in patients who undergo total hip arthroplasty for displaced femoral neck fractures.
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http://dx.doi.org/10.1016/j.artd.2020.07.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475170PMC
December 2020

Conversion total hip arthroplasty with a proximally modular, distal fixation reconstruction prosthesis following cephalomedullar nail failure.

Hip Int 2020 Sep;30(1_suppl):26-33

Orthopaedic and Traumatology Service, Hip Unit, Hospital Italiano de Buenos Aires, Buenos Aries, Argentina.

Background: The goals of intertrochanteric hip fracture (IHF) treatment are stable fixation, early mobilisation and function restoration. If the attempt to reduce, stabilise and fracture healing utilising a femoral cephalomedullar nail (CMN) fails, options for subsequent attempts are limited.

Purpose: Evaluate the clinical and radiographic outcomes of conversion total hip arthroplasty (THA) using a modular stem following a CMN failure.

Materials And Methods: We retrospectively reviewed a consecutive series of patients with an IHF between 2012 and 2014 to identify CMN patients that went on to the subsequent failure and conversion to THA utilising a modular femoral stem (MFS). In all cases, MP Reconstruction Prosthesis (Waldemar Link, Hamburg, Germany) was implanted. Primary clinical outcomes were assessed using Harris Hip Score (HSS) before conversion procedure, 3 months, 6 months and recent office visit post-conversion THA thereafter. The secondary outcome was to analyse intra and postoperative complications. Serial radiographs at each follow-up interval were assessed for clinical success or to confirm adverse events.

Results: 28 patients were included in the study; 17 were females. The average age was 72.7 years (SD ± 10.5); the average time from the index procedure to conversion THA was 12.6 months (SD ± 3.5). At baseline, average HHS was 42.1 (SD ± 3.6), improved to 80.7 (SD ± 5.1) at 3 months, 86.0 (SD ± 3.9) at 6-months which levelled off to 86.1 (SD ± 4.0) at final follow-up. There were 4 (14%) post-conversion complications: 2 dislocations, 1 superficial wound infection, 1 patient with symptomatic abductor deficiency. All 4 cases were conservatively treated successfully, the implants were retained, and the patients progressed without further issue.

Conclusions: MFSs allow to successfully treat failed CMN and adverse variations in femoral anatomy with a device that will permit simultaneous correction of leg length, offset and version to relieve pain, restore function and create a durable prosthetic to host composite.
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http://dx.doi.org/10.1177/1120700020937952DOI Listing
September 2020

International Organism Profile of Periprosthetic Total Hip and Knee Infections.

J Arthroplasty 2021 01 16;36(1):274-278. Epub 2020 Jul 16.

Orthopaedic Department, Helios Klinikum, Berlin, Germany.

Background: There is scarce literature describing pathogens responsible for periprosthetic joint infections (PJIs) around the world. Therefore, we sought to describe periprosthetic joint infection causative organisms, rates of resistant organisms, and polymicrobial infections at 7 large institutions located in North/South America and Europe.

Methods: We performed a retrospective study of 654 periprosthetic hip (n = 361) and knee (n = 293) infections (January 2006 to October 2019) identified at Cleveland Clinic Ohio/Florida in the United States (US) (n = 159), Hospital Italiano de Buenos Aires in Argentina (n = 99), Hospital Asociación Española in Uruguay (n = 130), Guy's and St Thomas' Hospital in the United Kingdom (UK) (n = 103), HELIOS Klinikum in Germany (n = 59), and Vreden Institute for Orthopedics in St. Petersburg, Russia (n = 104). Analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05.

Results: Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58% and there was a significant difference between hips (62.3%) and knees (52.6%) (P = .014). Rates of resistant organisms among countries were 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (P < .001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were 9.4% in the US, 11.1% in Argentina, 4.6% in Uruguay, 4.9% in UK, 11.9% in Germany, and 16.3% in Russia (P = .026).

Conclusion: In the evaluated institutions, S aureus and S epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections.
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http://dx.doi.org/10.1016/j.arth.2020.07.020DOI Listing
January 2021

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 17;28(9):2747-2755. Epub 2020 Aug 17.

CortoClinics, Schijndel, The Netherlands.

Purpose: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections.

Method: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations.

Results: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves.

Conclusions: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.
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http://dx.doi.org/10.1007/s00167-020-06213-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429418PMC
September 2020

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology.

Int Orthop 2020 10 8;44(10):1887-1895. Epub 2020 Aug 8.

'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina.

Purpose: To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology.

Methods: Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality.

Results: Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality.

Conclusion: Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.
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http://dx.doi.org/10.1007/s00264-020-04769-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414899PMC
October 2020

Simultaneous Bilateral Femoral Neck Fracture Due to a Tonic-Clonic Seizure and High-Dose Steroid Therapy.

Arthroplast Today 2020 Sep 14;6(3):513-516. Epub 2020 Jul 14.

Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Simultaneous bilateral femoral neck fractures (FNFs) are extremely rare and usually associated with an underlying condition affecting the bone quality and mineralization. Convulsions have also been described as a possible cause, mostly as a consequence of epilepsy, hyponatremia, and hypocalcemia. We present a 52-year-old female patient, with bilateral displaced FNFs due to a tonic-clonic seizure and high-dose steroid therapy related to a frontal lobe anaplastic oligodendroglioma brain tumor resection. Two days after admission, bilateral one-stage uncemented total hip arthroplasty (THA) under general anesthesia and through a posterolateral approach was performed using a metal-on-polyethylene bearing surface. Several risk factors can be identified in this unique case, such as the high-dose steroid therapy, the low-demand activity of the patient due to her functional sequelae, and finally, the convulsive episode. Surgeons should be aware of this uncommon injury to ensure early diagnosis and treatment in all patients with a previous history of seizures, chronic steroid use, severe hip pain, and inability to walk. For bone metabolic diseases, preventive measures should be indicated to avoid these complications. Bilateral one-stage uncemented THA represents an effective procedure with a low complication rate allowing early rehabilitation.
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http://dx.doi.org/10.1016/j.artd.2020.05.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364048PMC
September 2020

Hypovitaminosis D in lower extremity Joint Arthroplasty: A systematic review and meta-analysis.

J Orthop 2020 Sep-Oct;21:109-116. Epub 2020 Mar 25.

Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA.

The purpose of the current systematic review was to identify the prevalence of hypovitaminosis-D in LE-TJA patients; and outline the association between pre-operative hypovitaminosis and post-operative outcomes. A search of PubMed-Medline and the Cochrane-Library databases was performed for literature published before November 27th, 2019 The eighteen studies analyzed had a pooled prevalence for vitamin D insufficiency (20 - <30 ng/mL) and deficiency (<20 ng/mL) of 53.4% and 39.4%, respectively. Hypovitaminosis-D was associated with higher complication rates ( = 0.043), and a greater prevalence among septic versus aseptic revisions ( = 0.016). Therefore, pre-operative screening for hypovitaminosis-D can be beneficial in patients undergoing LE-TJA.

Level Of Evidence: Systematic Review (Level III).
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http://dx.doi.org/10.1016/j.jor.2020.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114851PMC
March 2020

Is there a Role for Antibiotic Prophylaxis Prior to Dental Procedures in Patients with Total Joint Arthroplasty? A Systematic Review of the Literature.

J Bone Jt Infect 2020 1;5(1):7-15. Epub 2020 Jan 1.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

: The indication of prophylactic antibiotics prior to dental procedures for non-infected causes in order to reduce the risk of haematogenous periprosthetic joint infection (PJI) remains as controversial. We performed a systematic review of the literature assessing the relationship between PJI and invasive dental procedures and whether there is evidence to support the use of antibiotic prophylaxis. : This review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched for studies focusing on dental procedures after TJA, reporting on PJI as an outcome. The methodological quality was assessed with the Newcastle-Ottawa quality assessment scale for case-control and cohort studies and by the tool proposed by Murad et al. for observational studies. : Our systematic literature review yielded 90 individual studies, of which 9 met the inclusion criteria. The overall infection rate ranged from 0.26% to 2.12%. Of these, cases associated with a dental procedure ranged from 0% to 15.9%. Five of the studies described cases in which antibiotic prophylaxis was administered; however, no clear algorithm regarding type and dosage of antibiotic was mentioned. When assessing the methodological quality of the evidence, all studies had an overall low to moderate quality. : The current systematic review, mostly composed of low-quality studies, suggests that there is no direct evidence to indicate prophylactic antibiotics prior to dental procedures in patients with TJA. In line with the current guidelines, no prophylaxis should be used on interventions for non-infected causes, except for occasional unusual situations, which can then be judged individually.
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http://dx.doi.org/10.7150/jbji.40096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045525PMC
January 2020

4- to 8-year complication analysis of 2 'partial collum' femoral stems in primary THA.

Hip Int 2021 Jan 26;31(1):75-82. Epub 2019 Sep 26.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Objectives: Compare the clinical and radiological outcome of CFP stem with the MiniHip design in a prospective series, with special interest in intraoperative periprosthetic fracture (IPPF).

Methods: We prospectively followed 101 cases treated with the MiniHip stem (Group 1) and 89 with the CFP stem (Group 2) operated between 2010 and 2014. No significant demographic differences were observed between both groups. Median follow-up was 72 months. Average stem length was 41% shorter in the MiniHip group (  0.001). Radiological parameters were measured and a logistcic regression model was created to evaluate factors associated with IPPF.

Results: Mean mHHS improved from 54 to 95 in the MiniHip group (  0.001) and from 64 to 98 in the CFP group (  0.001). No significant differences were observed in terms of loosening, infection or instability. We observed 7 IPPFs (3.68%), 3 in group 1 and 4 in group 2. After adjusting for confounders, CFP was not associated with a greater risk of IPPF (OR 3.23; 95% CI, 0.250-42.034,   0.368), however, a more complex fracture pattern was observed with this stem design. Prior acetabular fractures were associated with IPPF (OR 66.85; 95% CI, 1.142-3911,   0.043). Compared to Dorr A femurs, type Dorr B appeared protective against IPPF (OR 0.039; 95% CI, 0.001-1.109,   0.058). Valgus alignment tended to increase the risk of IPPF (OR 20.59; 95% CI 0.870-487.221,   0.061).

Conclusions: MiniHip showed similar radiological outcomes to CFP at short- to mid-term follow-up without increasing IPPFs with a shorter stem length. Given that CFP produced a more complex IPPF pattern, surgeons should be cautious with alignment of this particular design, especially in Dorr A femur.
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http://dx.doi.org/10.1177/1120700019879360DOI Listing
January 2021

Unaddressed arterial injuries in revision total hip arthroplasty: mortality outcomes of a low-prevalence complication.

Int Orthop 2020 01 20;44(1):23-29. Epub 2019 Jun 20.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, ACK1199, 4247 Potosi St, Buenos Aires, Argentina.

Purpose: Peri-operative major arterial haemorrhage after revision total hip arthroplasty (RTHA) is an odd but limb- and life-threatening complication. In this retrospective analysis, we sought to determine the prevalence of such injuries requiring selective catheter embolization or bypass after RTHA and to evaluate the associated mortality rate.

Methods: Between 1995 and 2016, 2524 RTHAs were performed at a high-volume centre (1031 one-stage revisions, 1370 two-stage revisions and 123 resection arthroplasties). Throughout this period, nine patients presented with signs of persistent bleeding unaddressed during index surgery (9/2524; 0.35%), causing haemodynamic instability. All patients underwent angiographic exploration within the first 24 post-operative hours. Angiography evidenced four cases of bleeding pseudoaneurysms (three of them related to the common femoral artery and one to the medial circumflex femoral artery) and five cases of direct lacerations (one case in the inferior epigastric artery, one in the hypogastric artery, one in the external iliac artery, one in the popliteal artery and another in the superior gluteal artery).

Results: Six cases underwent selective percutaneous angiographic embolization with gelatin microspheres, obtaining immediate haemodynamic stabilization; whereas three cases required a further bypass surgery with synthetic graft. Of the former group, four patients had an uneventful evolution, while two died at a mean of 49 days after surgery due to multi-organ failure (MOF). Two cases of the bypass group died because of MOF at a mean of 22 days. Overall mortality rate was 44%.

Conclusions: The overall risk of arterial injury associated with RTHA was low. However, recognition of such a complication is imperative since it was associated with a high mortality rate.
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http://dx.doi.org/10.1007/s00264-019-04358-2DOI Listing
January 2020

Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? A Complication Rate Analysis.

J Arthroplasty 2019 Sep 14;34(9):2051-2057. Epub 2019 May 14.

Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: Because the gold standard for the treatment of Vancouver type-B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate between the impaction bone grafting (IBG) technique with a cemented stem and reconstruction with an uncemented distally-fixed modular stem (DFMS).

Methods: We retrospectively studied 54 B3 PFFs operated between 2000 and 2016, comparing the complication rate of 33 patients treated with the IBG technique (group A) with 21 patients treated with a DFMS (group B). Median follow-up of groups A and B were 75 months (interquartile range [IQR], 36-111 months) and 55 months (IQR, 32-73 months), respectively (P = .008). Median age of groups A and B were 78 years (IQR, 74-83 years) and 81 years (IQR, 74-86 years), respectively (P = .30). Median grade of Endo-Klink femoral bone defect was 3 (IQR, 3-3) for both groups (P = .11). We performed a multiple regression analysis to determine risk factors for complications including the following variables: age, initial diagnosis, and surgical technique.

Results: As for infection outcomes, 2-stage revision surgery was more frequent in group A than in group B (4 vs 0, P = .003). Group A presented more implant failures than group B (5 vs 1, P = .195). We found 4 dislocations in group B and 2 in group A (P = .192). Multiple regression analysis showed a significant association between surgical technique and complication rate (P = .01). The IBG technique presented an odds risk for complications of 4.77 (P = .016; IQR, 1.33-17.21).

Conclusion: Femoral reconstruction with the IBG technique evidenced an ostensibly higher complication rate than that of DFMS for the treatment of B3 PFF.
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http://dx.doi.org/10.1016/j.arth.2019.04.047DOI Listing
September 2019

Aggressive granulomatosis of the hip: a forgotten mode of aseptic failure.

Int Orthop 2019 06 30;43(6):1321-1328. Epub 2018 Nov 30.

Hip Surgery Unit, Italian Hospital of Buenos Aires, Institute of Orthopaedics "Carlos E. Ottolenghi", 4247 Potosí St, C1199ACK, Buenos Aires, Argentina.

Purpose: It has been acknowledged that implant wear correlates with the risk for periprosthetic osteolysis, being aggressive granulomatosis the worst expression of bone resorption. We sought to determine the clinical, radiological, and histological features of aggressive granulomatosis after primary total hip arthroplasty (THA).

Methods: We included nine cases with aggressive granulomatosis of the hip around cemented stems. Indications for revision THA consisted of progressive signs of extensive bone resorption or implant loosening. Mean follow-up since revision THA was 143 months (SD ± 59.4). We analysed clinical outcomes, component loosening and gross as well as histological characteristics of the granulomatous lesions.

Results: Overall mean time between primary THA and revision surgery was 81 months (SD ± 20.8). All of the cases evidenced multiple ovoid tumour-like lesions around the stem with extensive bone loss. Only one case reported thigh pain before revision surgery, with radiological evidence of stem loosening; the remaining cases were asymptomatic with well-fixed implants. Gross anatomy findings revealed metallosis in the femoral canal and inside the cystic lesions. Pathology analysis showed monocyte-macrophage-dominated adverse foreign-body-type tissue reaction with fibroblastic reactive zones and granulomatous inflammation.

Conclusions: We found a prevalence of 1% of this aseptic mode of implant failure. Since most of the retrieved stems were not loose, we did not find any alarming clinical symptoms anticipating implant failure. In this scenario, surgeons should be aware of the rapidly progressive nature of this entity and propose a revision THA in a timely fashion.
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http://dx.doi.org/10.1007/s00264-018-4252-9DOI Listing
June 2019

Are there any risk factors for developing complications with the use of retrievable vena cava filters in orthopaedic surgery?

Rev Fac Cien Med Univ Nac Cordoba 2018 06 11;75(2):119-127. Epub 2018 Jun 11.

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Background: In high-risk patients, common prophylaxis may be insufficient to prevent thromboembolic events after orthopaedic procedures. In this scenario, a retrievable vena cava filter (VCF) could be considered as an alternative, although it's use remains controversial. Therefore, we asked: (1) what is the overall mechanical complication rate associated with the use of retrievable VCFs in orthopaedic surgery?, (2) what is the association with thromboembolic disease (TED) recurrence, post-thrombotic syndrome and/or major bleeding according to different surgical characteristics?, (3) What is the overall mortality rate attributed to VCF use?

Methods: We retrospectively analyzed a cohort of 68 patients who underwent orthopaedic surgery with a previous diagnosis of TED, in whom a retrievable VCF was placed. Permanent filters were excluded. We studied the filter's mechanical complications and considered as possible outcomes death and 3 hematologic complications: TED recurrence, post-thrombotic syndrome and major bleeding. To estimate association with risk factors, we subclassified surgeries into 5 groups: 1, arthroplasty/non-arthroplasty; 2, primary/revision; 3, elective/urgent; 4, oncologic/non-oncologic; 5, preoperative/postoperative filter.

Results: Mechanical complications were 16% and required a filter revision. Sixty-four percent of the revised VCFs developed a mechanical failure and could not be retrieved. Overall prevalence of TED recurrence, post-thrombotic syndrome and hemorrhage was 33%, 15% and 4.5%, respectively. Spinal surgeries were a risk factor for developing TED recurrences.  Only 4% of patients died of a TED recurrence.

Conclusions: Orthopaedic procedures had a high risk of mechanical and hematologic complications after using a retrievable VCF. However, mortality was low due to these complications.
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http://dx.doi.org/10.31053/1853.0605.v75.n2.17746DOI Listing
June 2018

State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty.

EFORT Open Rev 2018 Jul 17;3(7):434-441. Epub 2018 Jul 17.

Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina.

Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.
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http://dx.doi.org/10.1302/2058-5241.3.170032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129958PMC
July 2018

Periprosthetic stress fracture around a well-fixed type 2B short uncemented stem.

SICOT J 2018 30;4:33. Epub 2018 Jul 30.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Despite the theoretical advantages of uncemented short stems, postoperative thigh pain is still matter of concern and can be attributed to different causes. We report a peculiar case of a stress fracture around a short cementless stem with cervico-metaphyseal fixation in an otherwise healthy patient. We implanted a MiniHip stem in a 43 year-old male professional golf player for the treatment of primary osteoarthritis using a ceramic on ceramic bearing. Against medical advice, the patient started to play soccer at the 4th postoperative month and was completely asymptomatic to that extent; but at 8 months follow-up and without a history of trauma he started complaining about progressive hip pain. After ruling out infection and loosening, histological analysis from a bone biopsy confirmed the diagnosis of stress fracture. Although revision surgery was initially scheduled, pain started to decrease gradually with protected weight-bearing (crutches) and disappeared around the first postoperative year, remaining the patient asymptomatic at 2 and half years of follow-up, with radiographs depicting a healed fracture with a hypertrophic callus. We encourage surgeons to be aware of the existence of periprosthetic stress fractures as a source of thigh pain (sometimes intractable), and despite being infrequent, they should always be contemplated, providing that these cases can be managed conservatively with rest and limited weight-bearing. After this uncommon case, we suggest to align the stem in order to equally distribute loads onto the medial calcar and the lateral femoral cortical.
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http://dx.doi.org/10.1051/sicotj/2018031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6065269PMC
July 2018

Transfusion rate using intravenous tranexamic acid in hip revision surgery.

Hip Int 2018 Mar;28(2):194-199

Hip Surgery Centre "Sir John Charnley", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

Methods: We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

Results: Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

Interpretation: The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.
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http://dx.doi.org/10.1177/1120700018768655DOI Listing
March 2018

Re-admissions treble the risk of late mortality after primary total hip arthroplasty.

Int Orthop 2018 09 10;42(9):2015-2023. Epub 2018 Mar 10.

Hip Surgery Unit, 'Carlos E. Ottolenghi' Institute of Orthopaedics, Italian Hospital of Buenos Aires, 4247 Potosi St, ACK1199, Buenos Aires, Argentina.

Background: Following a total hip arthroplasty (THA), early hospital re-admission rates of 3-11% are considered as 'acceptable' in terms of medical care cost policies. Surprisingly, the impact of re-admissions on mortality has not been priorly portrayed. Therefore, we sought to determine the mortality rate after 90-day re-admissions following a THA in a series of patients from a captive medical care program.

Patients And Methods: We prospectively analysed 90-day readmissions of 815 unilateral, elective THA patients operated upon between 2010 and 2014 whose medical care was the one offered by our institution. We stratified our sample into readmitted and non-readmitted cohorts. Through a Cox proportional hazards model, we compared demographic characteristics, clinical comorbidities, surgical outcomes and laboratory values between both groups in order to determine association with early and late mortality.

Results: We found 37 (4.53%) re-admissions at a median time of 40.44 days (IQR 17.46-60.69). Factors associated with re-admission were hospital stay (p = 0.00); surgical time (p = 0.01); chronic renal insufficiency (p = 0.03); ASA class 4 (p = 0.00); morbid obesity (p = 0.006); diabetes (p = 0.04) and a high Charlson index (p = 0.00). Overall mortality rate of the series was 3.31% (27/815). Median time to mortality was 455.5 days (IQR 297.58-1170.65). One-third (11/37) of the re-admitted patients died, being sepsis non-related to the THA the most common cause of death. After adjusting for confounders, 90-day re-admissions remained associated with mortality with an adjusted HR of 3.14 (CI95% 1.05-9.36, p = 0.04).

Conclusions: Unplanned re-admissions were an independent risk factor for future mortality, increasing three times the risk of mortality.
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http://dx.doi.org/10.1007/s00264-018-3876-0DOI Listing
September 2018

Is a short stem suitable for patients with hip dysplasia? A report on technical problems encountered during femoral reconstruction.

Hip Int 2018 May 14;28(3):315-323. Epub 2017 Oct 14.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: A wide variety of stems have been used for the treatment of osteoarthritis secondary to advanced hip dysplasia. Since evidence for using short stems in dysplastic hips is limited, we planned to analyse the technical problems encountered when reconstructing the proximal femur of patients with osteoarthritis secondary to congenital dysplasia of the hip treated with total hip arthroplasty (THA) using a type 2B short stem.

Methods: We prospectively analysed 17 patients (22 hips) treated with primary THA performed with a single-branded short uncemented stem with metaphyseal fixation (MiniHip™; Corin). We excluded cases in which other type of stems were used, or in which retrospective data was only available. Mean follow-up was 41.22 months (minimum 24). We analysed clinical outcome using the modified Harris Hip Score (mHHS) and pain using the visual analogue scale (VAS). Radiographs were examined in order to determine causes of complications and revision surgery.

Results: All patients showed statistically significant improvement when preoperative and postoperative values for mHHS (54.19 vs. 94.57; p = 0.0001) and for pain VAS (8.71 vs. 0.71; p = 0.0003) were compared. No cases of thigh pain, instability or infection were found. 1 case of acetabular cup loosening and 1 case of periprosthetic fracture were diagnosed at 8 months and 45 days, respectively. Overall survival was 84.7% at 5 years (CI 95%, 64.4-105.3) with revision for any reason as an end point. When stem performance was separately evaluated, it showed a survival rate of 100% at 5 years with revision for aseptic loosening as an end point.

Conclusions: THA with a type 2B short stem for the treatment of dysplastic osteoarthritis showed very few technical intraoperative problems, being a useful alternative for femoral reconstruction.
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http://dx.doi.org/10.5301/hipint.5000562DOI Listing
May 2018

THA conversion rate comparing decompression alone, with autologous bone graft or stem cells in osteonecrosis.

Hip Int 2018 03 10;28(2):189-193. Epub 2017 Sep 10.

"Sir John Charnley" Hip centre, "Carlos E. Ottolenghi" Orthopaedic and Traumatology Institute, Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Core decompression (CD) with or without the addition of autologous bone graft (CDBG) is currently the most widely accepted treatment for hip osteonecrosis in stages of pre-collapse. The use of bone marrow mesenchymal stem cells (CDSC) is emerging as a promising biological alternative. We sought to determine the total hip arthroplasty (THA) conversion rate for patients treated with CD, CDBG or CDSC.

Material And Methods: Between 1996 and 2012, 97 cases were evaluated in 72 patients: 47 CD cases, 34 CDGB cases and 16 CDSC cases. The mean age was 39 (20-63) years, 25 bilateral, 19 female and 53 male, 14 Ficat 1 and 83 Ficat 2. Bilateral cases with asymmetric stage and equal treatment were excluded.

Results: Conversion rate to THA was 44% for the CD group (21/47) at an average of 77 (24-324) months; 50% for the CDBG group (17/34) at an average of 34 (24-240) months and 50% for the CDSC group (8/16) at an average of 48 (24-72) months (p = 0.619). Log Rank test for survivorship analysis was not significant (p = 0.2011). Immunodeficiency or corticosteroid treatment history was associated with 16/47 of the CD group, 7/34 in the CDBG group and 1/16 in the CDSC group. Trauma was associated with 2/47 of the CD group, 5/34 of the CDBG group and none of the CDSC group. Hazard ratio considering risk factors was not significant (p = 0.252).

Conclusions: In these series of cases including patients with pre-collapse osteonecrosis, we observed non-significant results regarding rate of conversion to THA with CD, CDBG or CDSC at an average of 5.5 years.
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http://dx.doi.org/10.5301/hipint.5000552DOI Listing
March 2018

Transfusion rate using intravenous tranexamic acid in hip revision surgery.

Hip Int 2017 Oct 12. Epub 2017 Oct 12.

Hip Surgery Centre "Sir John Charnley", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

Methods: We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

Results: Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

Interpretation: The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.
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http://dx.doi.org/10.5301/hipint.5000555DOI Listing
October 2017

Three cases of type-1 complex regional pain syndrome after elective total hip replacement.

SICOT J 2017 5;3:52. Epub 2017 Sep 5.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, 4247 Potosí St., C1199ACK Buenos Aires, Argentina.

Complex regional pain syndrome (CRPS) constitutes an atypical cause of pain after orthopaedic procedures. To our knowledge, there is a paucity of literature reporting this syndrome after total hip arthroplasty (THR), since only two case reports have been published. We thenceforth describe the clinical outcome of three cases of type-1 CRPS developed after elective THR, two of them initially diagnosed with secondary osteoarthritis whereas the remaining one presented a sequel of a failed osteosynthesis that required conversion to THR. Remission of disease was found at an average seven months (range: 4-9). Medical treatment involved a combined therapy of pain management, bisphosphonates and intense physical therapy. One patient was additionally treated with a corticosteroid blockade of his right sympathetic lumbar ganglia. None of the patients required surgical treatment. At final follow-up, physical examinations and imaging were negative for disease.
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http://dx.doi.org/10.1051/sicotj/2017038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579881PMC
September 2017

Outcomes of nondisplaced intracapsular femoral neck fractures with internal screw fixation in elderly patients: a systematic review.

Hip Int 2018 01;28(1):18-28

3 Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires - Argentina.

Introduction: Although the preferred treatment for displaced femoral neck fractures in the elderly is hip arthroplasty, the treatment for impacted or undisplaced femoral neck fractures (UFNF) is still a subject of controversy. Our purpose was to systematically review studies of elderly patients with UFNF treated with internal fixation using screws: (i) what is the reported mortality; (ii) what is the reoperation rate; (iii) what are the clinical and radiological outcomes; and (iv) what is the methodological quality of the included studies?

Methods: This systematic review was performed through a search of PubMed and the Cochrane database using a structured search algorithm including studies enrolling patients older than 60 years old, with UFNF treated with internal fixation using screws. Our literature search returned 950 studies and 11 were selected for final abstraction.

Results: 6 studies reported mortality rate. At 1-year follow-up mortality was reported by 3 studies: 18.8%; 22%, and 19%. At 5 years, 1 study reported mortality rate of 42%. Overall reoperation rate was reported by 9 studies and ranged from 8%-19%, while conversion to hip arthroplasty was performed in the range between 8% and 16% according to 6 studies.

Conclusions: Internal fixation with cannulated screws for UFNF in the elderly is a valuable option, although it has substantial reoperation and mortality rates. Further prospective high-quality, randomised controlled trials are required to establish the optimal approach for the treatment of UFNF.
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http://dx.doi.org/10.5301/hipint.5000532DOI Listing
January 2018

Arthroscopic acetabuloplasty without labral detachment for focal pincer-type impingement: a minimum 2-year follow-up.

J Hip Preserv Surg 2017 Jul 12;4(2):145-152. Epub 2017 Apr 12.

Hip Surgery Unit, Carlos E. Ottolenghi, Institute of Orthopaedics, Italian Hospital of Buenos Aires, 4247 Potosi St., Buenos Aires 1199, Argentina.

In order to access and resect the acetabular rim, arthroscopic acetabuloplasty was described with labral detachment. When the chondrolabral junction remains intact, acetabuloplasty and labral refixation can be performed maintaining an unharmed labrum. We aimed to evaluate the outcome of a group of patients treated with arthroscopic acetabuloplasty without labral detachment. During the study period, we retrospectively analysed 44 patients with pincer-type o combined impingement and an intact chondroblabral junction, with an average follow-up of 32 months (range: 27-38). We excluded patients with isolated CAM-type impingement and previous hip pathology. Radiographs were analysed to define impingement and classify grade of osteoarthritis. Clinical evaluation consisted of pre-operative and post-operative modified Harris hip score (mHHS) and WOMAC as well as post-operative visual analogue scale (VAS) of pain and satisfaction. Reoperations were considered surgical failures for purposes of survival analysis. Mean mHHS changed from 51.06 (SD 4.81) pre-operatively to 84.97 (SD 12.79) post-operatively. Pre-operative WOMAC was 29.18 (SD 8) and post-operative, 13.10 (SD 11). Post-operative VAS was 7.5 and 2.27 for satisfaction and pain, respectively. When comparing patients with Tönnis 0 to those with Tönnis 1, the former showed better results regarding post-operative mHHS (89.9 s versus 77.85,  = 0.03), pain VAS (1.5 versus 6.3,  = 0.03) and satisfaction VAS (8.2 versus 6.3,  = 0.01). Survival was 100% at 24 months and 76% at 40 months (95% CI: 35-98%). Arthroscopic acetabuloplasty without labral detachment achieved good clinical outcomes. Slight degenerative changes on radiographs correlated with poorer clinical outcomes.
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http://dx.doi.org/10.1093/jhps/hnx015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467423PMC
July 2017