Biologic treatment options for the hip: A narrative review The goal of surgery around the hip is to preserve both acetabular and femoral bone stock and to optimize function, specifically abductor function. Biologic options include allografts, allograft metal composites, and structural grafts that over time incorporate, are durable, and provide bone stock for future reconstruction(s). Reconstructive principles are guided by the defect(s) after tumor surgery, patient factors (age, chemotherapy, comorbid conditions), and graft availability. The challenges of reconstruction around the hip are stability of the joint and optimizing abductor function. For routine reconstructions around the hip for osteoarthritis and low-energy trauma, metal implants, either arthroplasty or internal fixation, are employed with high rates of success. Biologic implants are generally reserved for revision and oncologic surgery when large structural bone and soft-tissue defects are present. Structural allografts are used for both acetabular and femoral defects to replace bone and or conserve bone stock in anticipation of future reconstructions. Maintaining soft-tissue attachments and optimizing tension in the hip abductors also is an important consideration in optimizing function, especially in younger patients. Biologic options are also important in patients with prior arthroplasty who sustain periprosthetic fractures or develop tumors above or below existing constructs that require excision and reconstruction. Complications are common both early and late postoperatively. For this reason, patients must be apprised of the risks, and surgeons should be poised to take appropriate steps to mitigate and/or treat potential complications and to anticipate future reconstructions to preserve and enhance function.

Proximal femoral reconstructions: A European “Italian” experience. A case series Background: The aim of the study was to analyze our experience with a single system of modular proximal femoral replacement, evaluating oncologic results, complications, and functional results. Methods: We reviewed data on 38 patients (21 men and 17 women; mean age 59 y) treated with proximal femoral reconstructions by two orthopaedic surgeons. Reconstruction was performed in all patients with a MUTARS® modular proximal femoral prosthesis and an acetabular reconstruction in eight patients. Diagnoses included primary bone sarcomas (21), bone metastases (15), and radioinduced osteonecrosis (2). The stem was press fit in 11 patients and cemented in 27. Results: At a mean follow-up of 1.9 yr, 12 patients were alive with no evidence of disease, three have no evidence of disease after treatment of a recurrence or metastasis, 12 were alive with disease, and nine had died. The two with osteonecrosis were not included in this analysis. Complications occurred in seven patients: four type I (wound dehiscence in one and dislocation in three), one type II, one type IV, and one type V failures, while type III failures did not occur. At last follow-up, 89% of patients (34/38) had retained their implant. The mean Musculoskeletal Tumor Society (MSTS) score was 24.7 (14-30), with excellent or good results in all patients except one. Conclusion: The overall survival of this prosthesis was satisfactory with good implant survival in proximal femoral reconstruction. The most frequent cause of failure was dislocation. The incidence of infection was low. Functional results were good or excellent. Level of Evidence: IV; case series.

Resection arthroplasty of the shoulder and hemiarthoplasty in the setting of infection: A narrative review Failure after anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) leaves few options secondary to loss of bone stock and derangement of the soft tissues. Treatment modalities for prosthetic joint infection are as diverse as their efficacy and morbidity. Single- or two-stage revision arthroplasty is an option for treating prosthetic joint infections in patients who can be treated surgically. The use of an antibiotic cement spacer as definitive treatment also has been shown in recent literature to be a viable treatment in medically tenuous patients or in patients with infections. The utility of a hemiarthroplasty with an antibiotic-coated stem (functional spacer) has been shown to provide good pain relief in over half of patients, and conversion of a hemiarthroplasty to a reverse TSA can be performed with improvement in both motion and function. Two-stage revision methods have the highest likelihood of restoring function, with a reported 60% to 90% success rate. While arthrodesis and amputation are options in life-threatening infections or the severely ill patient, resection arthroplasty remains an option as a limb and limited motion-sparing alternative.

Cones and sleeves in knee arthroplasty: a narrative review Total knee arthroplasty (TKA) volume is expected to continue increasing worldwide. In Australia last year TKA increased 2.8% from the previous year. This trend has led to an increasing rate of revision TKA procedures for loosening, infection, and periprosthetic fracture. Periprosthetic bone loss can present challenges, and various techniques have been described to manage this intraoperatively. This review article discusses the indications and advantages of cones and metaphyseal sleeves in cases involving bone loss.

Effect of asymptomatic bacteriuria treatment prior to total hip or knee arthroplasty on hospital outcomes: A retrospective cohort study Background: Although treatment of asymptomatic bacteriuria (ASB) in patients undergoing total hip (THA) or knee (TKA) arthroplasty does not seem to effect the rate of secondary joint infections (SJI), the effect on hospital outcomes has yet to be evaluated. This study aimed to determine the clinical effect of ASB treatment in TKA or THA on hospital outcomes. Methods: A retrospective evaluation of patients undergoing TKA or THA with the presence of ASB was conducted. Inclusion criteria were TKA or THA and presence of ASB. Patients were excluded if symptomatic, receiving nonspecified antibiotics, catheterized, or pregnant. The primary outcome was comparing differences in time from admission to TKA or THA procedure in groups treated for ASB versus an untreated group. Secondary outcomes were length of stay (LOS) and rates of SJI. Results: A total of 1683 patients were screened, and 133 patients with ASB were included (53 treated; 80 untreated). Median time from admission to procedure was not statistically different between groups (3.63 hr [3.10-5.57 hr] treated vs. 3.68 hr [3.07-5.17 hr] untreated; P=0.412). An increase in LOS was observed in the treated group (3.4 days [3.15-4.36 days] treated vs. 2.36 days [2.21-3.35 days] untreated; P<0.0001). Rates of SJI were not different between groups (P=0.646). Conclusions: Although time from admission to TKA or THA procedure was not different between groups, a longer LOS was identified in the treated group. There was no difference in rates of SJI between groups. Larger studies are needed to determine if treating ASB for TKA or THA should be discontinued. Level of Evidence: Level III.

Femoral-side revision using dual-mobility components for failed hip resurfacing: A retrospective case series Background: The aim of this study was to report clinical outcomes and complications of femoral-side revision using dual-mobility components for failed hip resurfacing. Methods: Eighteen consecutive patients underwent revision of failed hip resurfacing for the femoral side using dual mobility components with acetabular component retention. The mean follow-up period was 18 mo. Results: The modified Harris Hip score, visual analog scale, and Short-Form (SF)-12 scores had all improved significantly (P<0.01, P<0.05 and P<0.05, respectively) with no evidence of loosening, dislocations, or any other complications. Conclusions: Femoral-side revision only using dual-mobility liners in failed hip resurfacing appears to be a simple, safe technique with high success.

Total shoulder arthroplasty: risk factors for a prolonged length of stay. A retrospective cohort study Background: Recent studies describe safe outcomes for outpatient total shoulder arthroplasty. This study identifies risk factors for hospital admissions exceeding 24 hr. Methods: The National Surgical Quality Improvement Program database was queried for billing codes related to total shoulder arthroplasty. Patients were grouped according to length of stay, ≤24 hr or >24 hr. Univariate and multivariate analyses were used to identify patient demographics, preoperative comorbidities, and intraoperative risk factors for prolonged hospitalizations. Results: Of the 14,339 patients who met the inclusion criteria, 6,507 patients (45.3%) had a length of stay ≤24 hr. Multivariate analysis identified age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.03), American Society of Anesthesiology classification (OR, 1.5; 95% CI, 1.4-1.6), diabetes (OR, 1.7; 95% CI, 1.4-2.0), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.2-1.6), congestive heart failure (OR, 2.7; 95% CI, 1.3-5.3), dialysis (OR, 2.5; 95% CI, 1.3, 4.8), history of a bleeding disorder (OR, 1.5; 95% CI, 1.2-1.9), and operative time (OR, 1.01; 95% CI, 1.01-1.01) as risk factors for prolonged hospitalization. Male gender was a protective factor for prolonged hospitalization (OR, 0.50; 95% CI, 0.46-0.53). Conclusions: Female gender, increasing age, American Society of Anesthesiology classification, operative time, or a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, or a bleeding disorder are risk factors for prolonged hospitalization following total shoulder arthroplasty. Level of Evidence: Level III.

Short-column acetabular fracture fixation through a mini-pararectus approach in anteriorly displaced acetabular fractures: A case series Background: A mini-pararectus approach has been described as a minimally invasive approach for stabilizing acetabular fractures. This approach allows a direct view of anteriorly displaced acetabular fractures. In this preliminary study, we report the outcomes of short-column plating, using either a pelvic-brim plate or a spring plate to stabilize anteriorly and medially displaced fractures. Methods: Nine patients were included in this report, which was conducted between June 2015 and October 2016 in Assiut University Hospital, which is a level 1 trauma center in Upper Egypt. Eight patients had a transverse fracture of the acetabulum, and a single patient had a posterior hemi-transverse fracture of the anterior column. After the mini-pararectus approach through which anatomical reduction of the fracture was achieved, short-column plating, either a pelvic-brim plate or spring plate was introduced through this 3-5 cm incision. Outcomes were assessed. Results: The mean operative time was 88.8 min (range, 60-120 min). The mean blood loss was 78.8 mL (range, 50-150 mL). The maximal fracture displacement mean was 7 mm (range, 4–18 mm) preoperatively. According to the Radiologic Matta score, anatomical reduction of the fracture (0–1 mm displacement) was achieved in all patients. No complications of metal failure or secondary fracture displacement were encountered. Conclusions: Short-column plating through a mini-pararectus approach can be an alternative option for stabilizing acetabular fractures in a minimally invasive way in selected patients. Level of Evidence: Level IV.

Factors influencing time to union of diaphyseal humeral fractures after plate fixation: A retrospective cohort study Background: We sought to determine time to union of diaphyseal humeral fractures treated with plate fixation and to identify underlying contributing factors. Methods: A retrospective cohort study of patients at a Level 1 trauma center from January, 2006 to December, 2016 was performed. The clinical intervention studied was surgical plate fixation, and the main outcome measure was time to union. Results: One hundred and thirty-five patients were included, with mean age of 40.67 (range: 18-90) and body mass index of 29.8 (range: 18.5-74.4). The mean time to union was 19.0 wk with a nonneurological complication rate of 8.9% (eight nonunions [5.95%], one malunion, one implant failure, and two infections). There was no correlation between age or body mass index and time to union. No difference was seen in time to union when comparing males versus females (17.9 vs. 20.1; P=0.3477), smokers versus nonsmokers (22.8 vs. 20.3, P=0.4237), anterior versus posterior approach (18.5 vs. 19.3; P=0.5798), and bridging versus rigid technique (17.6 vs. 19.6; P=0.4453). There was no difference in time to union between proximal, middle, or distal diaphyseal fracture location. There was a trend toward longer time to union in open fractures versus closed and a significantly increased risk of nonunion in open fractures (22.2% vs. 3.4%; P=0.0110). Overall time to union is slightly increased when compared to previously published data. Conclusions: Open fracture results in both increased time to union and rate of nonunion after plate fixation. There is no difference in time to union between surgical approaches and techniques, as well as in age, body mass index, gender, smoking, or fracture location. Level of Evidence: Level III.

Clinical significance of bone morphogenetic protein in osteosarcoma: A systematic review Background: The literature suggests that endogenous bone morphogenetic proteins (BMP) have both beneficial and deleterious effects on osteosarcoma. Therapeutic use of exogenous BMP after osteosarcoma resection to enhance skeletal reconstruction is controversial. Methods: We conducted a systematic review to determine the association of endogenous BMP expression and overall survival for osteosarcoma patients to determine the association of BMP expression and metastasis, and to evaluate the extent of clinical evidence regarding use of recombinant human BMP (rhBMP) in patients with osteosarcoma. Results: Eight studies were included; all except one reported on endogenous BMPs or BMP receptor. The four clinical studies on an association between BMPs and prognosis had mixed results; one associated BMP-7 expression with improved overall survival (OS) in osteosarcoma, while another found no correlation between BMP-6, 7, or 8 with OS. In contrast, one found a negative correlation between BMP expression and prognosis. The final study of these four investigated BMP-2 single nucleotide polymorphisms (SNP) in osteosarcoma and reported an association of a specific SNP mutation with improved prognosis. All three studies addressing metastasis reported increased risk for metastasis of osteosarcoma with either BMP-2 receptor or BMP-2 or 4 expression. Only one study evaluated application of therapeutic rhBMP-2 after osteosarcoma resection, finding no effect on clinical outcomes and no detrimental effects such as tumor recurrence. Conclusions: Endogenous BMP or BMP receptor expression may be associated with osteosarcoma metastasis but are of uncertain prognostic significance. Any harmful or beneficial effects of exogenous therapeutic BMP application in this setting are unproven.