Secondary Osteoarthritis Research Articles

Cell therapy for osteonecrosis of femoral head and joint preservation

Osteonecrosis of femoral head (ONFH) is a disease of the femoral head and can cause femoral head collapse and arthritis. This can lead to pain and gait disorders. ONFH has various risk factors, it is often progressive, and if untreated results in secondary osteo-arthritis. Biological therapy makes use of bone marrow concentrate, cultured osteoblast and mesenchymal stem cell (MSC) obtained from various sources. These are often used in conjunction with core decompression surgery. In this review article, we discuss the current status of cell therapy and its limitations. We also present the future development of biological approach to treat ONFH.

Mueller Weiss syndrome, a less elucidated and unusual cause of midfoot pain: A case report

Mueller Weiss Syndrome is a rare, under-diagnosed cause of chronic mid foot pain despite having well-described imaging features. It is historically described as spontaneous adult-onset osteonecrosis of the navicular bone. The disease commonly affects bilateral navicular bones in women in the fifth decade of life. Nearly a century after its first description as a disease entity, the exact etiopathogenesis is still not well understood. From a radiographic point of view weight-bearing radiographs of the foot remains the mainstay in diagnosis. Characteristic imaging findings include the lateral collapse of navicular, dorsomedial subluxation of the remnant navicular, and lateral deviation of the talus (hind-foot varus). Progressive disease leads to pes planus and secondary osteoarthritis of the talonavicular joint with or without the involvement of other midfoot joints. Severe disease may show “listhesis navicularis” and talo-cuneiform neo-articulation. Computed tomography and magnetic resonance imaging can be used as adjuncts, especially to detect changes in the initial stage of the disease and early osteoarthritic features.

An Observational Study to Assess Samprapti Ghataka in Cervical Spondylosis with Special Reference to Radiological Findings

The western lifestyle, characterized by convenience food, television and PC’s taking its all on children as well as adults and is producing increased number of overweight, passive youngsters with lifestyle diseases. Spondylosis is degenerative inter vertebral disc with secondary proliferative osteoarthritis. Disc spaces collapse and associated ligament thickening and bony proliferation result in nerve root compression and narrowing of spinal canal. Cervical spondylosis which is a degenerative disorder in which structural and also functional derangements take place. It is an age related and also work-related disability usually found in the 30-60 years of age group. According to Ayurveda it is one among the Vataja Nanatmaja Vikara. There is no exact clinical entity mentioned in classics like cervical spondylosis, but it can be compared to Greevastambha, Apabahuka, Vishwachi Manyastamba, Manyagraha, Shirograham, Greevahundanam, Greevasandhigatavata. Cervical Spondylosis also known as cervical osteoarthritis or neck arthritis, is a common age-related condition that affects the joints and discs in our neck.

Custom Made Implant in Revision Knee Arthroplasty with AORI 3 Bone Defect: а Case Report

Background. Replacement of extensive bone defects during revision knee arthroplasty (RKA) is a certain problem. The development of additive technologies allows us to produce an individual titanium augment to restore the lost bone tissue. The aim of the study is to show the possibility of replacing extensive tibia defects with an custom made augment during revision knee artroplasty. Case presentation. The patient is 66 years old. At the age of 58, due to secondary knee osteoarthritis in 2 years interval, the patient underwent total knee arthroplasty: left in 2012, right in 2014. Subsequently, several revision interventions were required for early periprosthetic infection of the right knee joint. From 2015 to 2018, due to the infection remission, the function of the right knee joint was satisfactory. In 2018, the patient admitted to our clinic with the periprosthetic infection relapse. Due to the previous treatment, the patient had type 3 bone defect according to the AORI classification. A two-stage revision knee arthroplasty was performed. To compensate the extensive tibial defect, the individual tibial implant was manufactured using additive technologies, and a semiconstrained endoprosthesis was implanted. There was no relapse of infection during the observation. There is deficit of active extension, there are no radiological signs of the implant instability. Conclusion. In our case, we were able to achieve satisfactory results in patient with a complex anamnesis and extensive bone defects. The use of individual implant helped to avoid arthrodesis, preserve the weight-bearing of the lower limb and articulation in the knee joint. The use of implants made using 3D technologies is a promising solution for compensating defects of types 2B and 3 according to the AORI classification.

Simultaneous asymmetrical bilateral hip dislocations – A report of three cases with different presentations and management

BackgroundSimultaneous traumatic dislocation of both the hips in an individual is an uncommon injury. It accounts for only 1–2% of all traumatic hip dislocations. Simultaneous traumatic dislocation of both the hips in opposite directions i.e., anterior dislocation of one hip and posterior of the other is even rarer. These asymmetric dislocations need prompt identification for appropriate management. While their management should proceed in a manner commensurate with the accepted management of isolated dislocations to avoid complications, it is the timely identification which is essential. Study detailsRetrospectively the details of three patients with asymmetric bilateral hip dislocations were collected. The article describes the clinical presentation of each patient and the management offered to them. The follow up duration ranged from 15 months to 24 months. ResultsIn the short term, the outcomes in terms of hip pain, movements at the hips and radiological parameters like absence of arthritic or avascular changes were found to be satisfactory in each patient. ConclusionEarly diagnosis and prompt reduction is the essential first step in the appropriate management of these patients to prevent the possible complications. The associated fractures must be managed as per the established principles of trauma care. Long term follow up is essential for identifying if complications like avascular necrosis and secondary osteoarthritis develop after this uncommon injury.

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.

Description of Joint Alterations Observed in a Family Carrying p.Asn453Ser COMP Variant: Clinical Phenotypes, In Silico Prediction of Functional Impact on COMP Protein and Stability, and Review of the Literature.

The role of genetics in the development of osteoarthritis is well established but the molecular bases are not fully understood. Here, we describe a family carrying a germline mutation in COMP (Cartilage Oligomeric Matrix Protein) associated with three distinct phenotypes. The index case was enrolled for a familial form of idiopathic early-onset osteoarthritis. By screening potential causal genes for osteoarthritis, we identified a heterozygous missense mutation of COMP (c.1358C>T, p.Asn453Ser), absent from genome databases, located on a highly conserved residue and predicted to be deleterious. Molecular dynamics simulation suggests that the mutation destabilizes the overall COMP protein structure and consequently the calcium releases from neighboring calcium binding sites. This mutation was once reported in the literature as causal for severe multiple epiphyseal dysplasia (MED). However, no sign of dysplasia was present in the index case. The mutation was also identified in one of her brothers diagnosed with MED and secondary osteoarthritis, and in her sister affected by an atypical syndrome including peripheral inflammatory arthritis of unknown cause, without osteoarthritis nor dysplasia. This article suggests that this mutation of COMP is not only causal for idiopathic early-onset osteoarthritis or severe MED, but can also be associated to a broad phenotypic variability with always joint alterations.

Total hip replacements following acetabular fractures. 7 to 15 years clinical and radiological results

This study is reporting the long term clinical and radiographic results of a group of 45 patients who underwent total hip arthroplasty following acetabular fractures. The study included 39 males and 6 females. The age of the patients ranged from 32 to 61 with a mean of 46.4 years. The indication for surgery was secondary osteoarthritis in 35 patients and avascular necrosis of the femoral head in the remaining ten. The follow up period ranged from 7 to 15 years with a median of 10.3 years. Uncemented total hip prostheses were used in 37 cases while 8 cases had hybrid prostheses with cemented cups and uncemented stems. Thirty patients (66.7%) needed autogenous acetabular bone grafting. There has been a statistically significant improvement from a preoperative mean Oxford hip score of 16 to a postoperative mean score of 39.8 (p < 0.001). At the end of follow up, two cases had revision for cup loosening. The complications included one case of transient sciatic nerve palsy, and two cases of heterotopic ossification. Currently, total hip replacement remains the best option for end stage post traumatic arthritis. There are technical challenges associated with this replacement surgery which the surgeon should be aware of.

Acetabular reconstruction with femoral head autograft in primary total hip arthroplasty through a direct anterior approach is a reliable option for patients with secondary osteoarthritis due to developmental dysplasia of the hip

BackgroundDevelopmental dysplasia is challenging to treat with total hip arthroplasty via the direct anterior approach (DAA). Reconstructing the former anatomy while restoring the acetabular bone stock for future revisions in this young patient collective combined with the known advantages of the DAA would be desirable. The purpose of this study was to analyze the feasibility, radiographic outcome and clinical outcome of primary uncemented total hip arthroplasty with bulk femoral head autograft for acetabular augmentation through a DAA with a minimal follow-up of 12 months.MethodsA retrospective, consecutive series from March 2006 to March 2018 of 29 primary total hip arthroplasty with acetabular augmentation with bulk femoral head autograft through a direct anterior approach was identified. All complications, reoperations and failures were analyzed. Radiographic and clinical outcome was measured.Results24 patients (29 hips) with a mean age of 43 (18–75) years and a mean follow-up of 35 months (12–137) were included. Surgical indication was secondary osteoarthritis for developmental dysplasia of the hip (Hartofilakidis Grade A (n = 19), B (n = 10)) in all cases. We noted no conversion of the approach, no dislocation and no acetabular loosening. The center of rotation was significantly distalized by a mean of 9 mm (0–23) and significantly medialized by a mean of 18 mm (6–29). The bone graft was fully integrated after 12 months in all cases.ConclusionAcetabular reconstruction with femoral head autograft in primary THA through a direct anterior approach seems to be a reliable option for the treatment of secondary osteoarthritis in patients with DDH Hartofilakidis grade A and B. Prospective cohort studies with a large sample population and a long-term follow-up are necessary to confirm our findings.

A potential diagnostic serum immunological marker panel to differentiate between primary and secondary knee osteoarthritis.

Inflammation contributes to knee osteoarthritis (KOA) where many immunological mediators participate in its initiation and progression. Most clinicians manage primary (pKOA) and secondary osteoarthritis (sKOA) alike. Whether immunological profiles of pKOA and sKOA differ remains obscure. Hence, we aimed to differentially identify potential serum immunologic diagnostic markers of pKOA and of sKOA. This case control study used 46 KOA patients (pKOA, n = 30; sKOA, n = 16), and 60 age, gender matched controls (normal healthy, n = 30; systemic lupus erythematosus [SLE] disease controls, n = 30) where serum was assayed for cytokines (TNF-α, IL-1β, IL-6, IL-10) and nitric oxide derivatives (NOx). Sandwich ELISA assessed cytokine levels, while the 'Griess assay' quantified NOx levels. The diagnostic accuracy of optimal marker combinations was evaluated by the CombiROC web tool. Compared with pKOA, sKOA serum displayed significantly elevated levels of pro inflammatory cytokines (TNF-α, IL-1β, IL-6) with a concurrent decrease in the anti-inflammatory cytokine, IL-10 (P<0.05). This was reiterated by significantly higher Th1:Th2 (TNF-α: IL-10) serum cytokine ratio observed in sKOA compared to that of pKOA. The CombiROC curves identified TNF-α, IL-1β, IL-6 and NOx as the best performing panel of potential diagnostic markers to discriminate pKOA from control groups (~97% accuracy, 90% Sensitivity [SE] and 98% specificity [SP]), while TNF-α, IL-1β and IL-6 discriminated sKOA from control groups (~100% accuracy, 100% SE, and 98% SP). The study identified discrete serum immune biomarker panels to differentiate between pKOA (TNF-α, IL-1β, IL-6 and NOx) and sKOA (TNF-α, IL-1β and IL-6). These findings may assist in developing distinct therapeutic agents for the two types of KOA.

Acetabular Fractures with Central Hip Dislocation: A Retrospective Consecutive 50 Case Series Study Based on AO/OTA 2018 Classification in Midterm Follow-Up.

Introduction Management of acetabular fractures is challenging, especially when a medial acetabular fracture is complicated by central hip dislocation. We retrospectively investigated the clinical outcome and risk factors of secondary hip osteoarthritis requiring total hip arthroplasty after the surgical treatment of acetabular fractures with central hip dislocation. Materials and Methods The medical records of all patients who had acetabular medial wall fractures with central hip dislocation treated with open reduction and internal fixation by a single surgeon between January 2015 and June 2017 were reviewed. Surgical reduction was performed with the modified Stoppa with/without the Kocher-Langenbeck (KL) approach. Patients were followed for a minimum of three years, and the Majeed scoring system was used for functional evaluation. Multivariate logistic regression analysis was used to assess the association of patients' characteristics with the likelihood of advanced posttraumatic arthritis developing with conversion to total hip arthroplasty. Results Fifty patients were included in this study, with disease classified as AO/OTA 2018 62B/62C. Thirty-five patients (70%) had good or excellent Majeed pelvic scores. Eleven patients (22%) eventually received total hip arthroplasty because of end-stage posttraumatic arthritis. Three risk factors identified for total hip arthroplasty were male sex, initial marginal impaction, and sciatic nerve injury. Kaplan-Meier survivorship analysis estimated that the cumulative probability of free-from-end-stage arthritis was 78% (95% confidence interval, 73%–90%) at the 5-year follow-up. Conclusion Surgical fixation with the modified Stoppa and the KL approach for acetabular medial wall fractures with central hip dislocation is an effective approach with a satisfactory functional outcome. A prodromal factor was marginal impaction concomitant with articular damage. The trauma of high axial loading and the occupational distribution (males performing heavy manual labor and heavy lifting) with preoperative sciatic nerve injury increased the odds of developing end-stage arthritis.

Calcified cartilage differs in patients with end-stage primary osteoarthritis and secondary osteoarthritis due to rheumatoid arthritis of the hip joint

Objectives Despite distinct aetiologies, the end-stages of primary osteoarthritis (OA) and secondary OA are described by common radiological features. However, the morphology of the bone–cartilage unit may differ depending on the pathogenesis. In this cross-sectional study, we aimed to investigate the histological differences in the bone–cartilage unit of the femoral head between patients with primary OA and secondary OA due to rheumatoid arthritis (RA). Method Femoral heads were obtained from 12 patients with primary OA, six patients with secondary OA due to RA, and 12 control subjects. The femoral heads were investigated using stereological methods to ensure unbiased quantification. Results The volume (mean difference [95% confidence interval]) (2.1 [0.5;3.8] cm3, p = 0.016) and thickness (413 [78.9;747] µm, p = 0.029) of the articular cartilage and the thickness of the calcified cartilage (56.4 [0.4;113] µm, p = 0.017) were larger in patients with primary OA than in patients with secondary OA due to RA. Femoral head volume (1.2 [−3.6;6.1] cm3, p = 0.598), bone volume fraction (−1.1 [−2.8;5.1] cm3, p = 0.553), subchondral bone thickness (−2.5 [−212;207] µm, p = 0.980), and osteophyte area (25.3 [−53.6;104] cm2, p = 0.506) did not differ between patients. Conclusion The thicker calcified cartilage in primary OA preceding the loss of articular cartilage can be attributed to endochondral ossification. Patients with secondary OA due to RA had severely thinner calcified cartilage as the pathogenesis is driven by inflammation and is characterized by a generalized and more severe loss of articular cartilage.

Harris Hip Score and SF-36 following metal-on-metal total hip arthroplasty and hip resurfacing - a randomized controlled trial with 5-years follow up including 75 patients

BackgroundThe metal-on-metal large-diameter-head (MoM-LDH) hip replacements increased in popularity during the start of the twenty-first century. Subsequently reports raised concerns regarding adverse reactions due to elevated chromium (Cr) and cobalt (Co) concentrations as well as high rates of other complications and revisions.The purpose was to compare Harris Hip Score and SF-36 at 5-years follow up following MoM-LDH total hip arthroplasty (MoM-LDH-THA) or MoM hip resurfacing (MoM-HR).MethodsThe study was conducted between November 2006 to January 2012 in a tertiary health care center in Denmark. Patients with primary or secondary osteoarthritis were randomly assigned to receive a Magnum (MoM-LDH-THA) or a Recap (MoM-HR) prosthesis. Randomization was computer generated and allocation was concealed in an opaque envelope. Neither patients nor care provider were blinded. Primary outcome was Harris Hip Score at 5-years follow up.ResultsSeventy-five were included and allocated to the MoM-LDH-THA (n = 39) and MoM-HR (n = 36) group. The study was prematurely stopped due to numerous reports of adverse events in patients with MoM hip replacements. Thirty-three in the MoM-LDH-THA and 25 in the MoM-HR group were available for primary outcome analysis.Median Harris Hip Score was 100 (IQR: 98–100) for MoM-LDH-THA and 100 (IQR: 93–100) for MoM-HR (p = 0.486). SF-36 score was high in both groups with no significant difference between groups.ConclusionHarris Hip Score and SF-36 score was excellent in both groups with no significant difference at 5-years follow up. Our findings suggest that there is no clinical important difference between the two prostheses implanted 5 years after implantation.Trial registrationClinicalTrials.gov, NCT04585022, Registered 23 September 2020 – Retrospectively registered.This study was not prospectively registered in a clinical trial database since it was not an entirely implemented standard procedure in the international orthopedic society when the study was planned.

Operative management of isolated posterior cruciate ligament injuries improves stability and reduces the incidence of secondary osteoarthritis: a systematic review.

To evaluate the evidence for operative and non-operative management of isolated posterior cruciate ligament (PCL) injuries. Using Pubmed, EMBASE and Cochrane databases, a systematic review was conducted of studies investigating the treatment of isolated PCL injuries published until July 2020. Quality assessment was performed with the Cochrane risk of bias tool (level I), the Newcastle-Ottowa Scale (level II-III) and the National Institute of Health quality assessment tool (level IV). Clinical outcome measures included residual laxity, return to sports, patient-reported outcome measures, subsequent articular degeneration and complications. Twenty-seven studies [23 case series, 2 case-control, 1 cohort study and 1 randomized controlled trial (RCT)] including 5197 patients (5199 knees) with a mean age of 29.5 ± 3.6years (range 15-68) fulfilled the study requirements. Significantly less residual laxity was found after posterior cruciate ligament reconstruction (PCLR) compared to non-operative management (3.43 vs. 5.47mm, CI: 1.84-2.23, p < 0.001). Both treatment modalities yielded satisfying functional outcomes and a high return to sports (64-77%, mean: 70.3, CI: 67.8-72.2). Osteoarthritis (OA) occurred less frequently following PCLR (21.5 vs. 44.1%, p < 0.001). In the absence of level I RCTs, this systematic review suggests that surgical management for selected isolated PCL injuries is a reasonable option to consider, especially when the surgeon aims at minimizing residual laxity and presumably secondary osteoarthritis. IV.

Preoperative T2 mapping MRI of articular cartilage values predicts postoperative osteoarthritis progression following rotational acetabular osteotomy.

Rotational acetabular osteotomy (RAO) has been reported to be effective in improving symptoms and preventing osteoarthritis (OA) progression in patients with mild to severe develomental dysplasia of the hip (DDH). However, some patients develop secondary OA even when the preoperative joint space is normal; determining who will progress to OA is difficult. We evaluated whether the preoperative cartilage condition may predict OA progression following surgery using T2 mapping MRI. We reviewed 61 hips with early-stage OA in 61 patients who underwent RAO for DDH. They underwent preoperative and five-year postoperative radiological analysis of the hip. Those with a joint space narrowing of more than 1 mm were considered to have 'OA progression'. Preoperative assessment of articular cartilage was also performed using 3T MRI with the T2 mapping technique. The region of interest was defined as the weightbearing portion of the acetabulum and femoral head. There were 16 patients with postoperative OA progression. The T2 values of the centre to the anterolateral region of the acetabulum and femoral head in the OA progression cases were significantly higher than those in patients without OA progression. The preoperative T2 values in those regions were positively correlated with the narrowed joint space width. The receiver operating characteristic analysis revealed that the T2 value of the central portion in the acetabulum provided excellent discrimination, with OA progression patients having an area under the curve of 0.858. Furthermore, logistic regression analysis showed T2 values of the centre to the acetabulum's anterolateral portion as independent predictors of subsequent OA progression (p < 0.001). This was the first study to evaluate the relationship between intra-articular degeneration using T2 mapping MRI and postoperative OA progression. Our findings suggest that preoperative T2 values of the hip can be better prognostic factors for OA progression than radiological measures following RAO. Cite this article: Bone Joint J2021;103-B(9):1472-1478.

The prevalence of femoroacetabular impingement in asymptomatic hips in Indian population: a radiomorphometric analysis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Femoroacetabular impingement (FAI) is a common cause of secondary osteoarthritis of the hip. There are no much studies about the occurrence of FAI in asymptomatic individuals in Indian population. Our objective was to find out the radiological prevalence of FAI in asymptomatic adult Indian population.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A cross sectional study was carried out in our institution, which is a tertiary care centre, between September 2016 and September 2018 in which in which we studied radiographs of 1600 hips from 800 pelvic x-rays of asymptomatic patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results: &lt;/strong&gt;Out of 1600 radiographs of the hips studied 1353 were found to be normal and the remaining 247(15.4%), had features of FAI. 61 hip radiographs (3.8%) showed cam lesions and 9.2 % showed pincer type of lesion.38 hips (2.4%) showed mixed type of FAI.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Significant number of radiographs of asymptomatic patients showed features of FAI. Further long-term studies are needed to see the proportion of these patients with FAI progressing to secondary osteoarthritis of hip.&lt;/p&gt;

No increased mortality after total hip arthroplasty in patients with a history of pediatric hip disease: a matched, population-based cohort study on 4,043 patients

Background and purpose — Patients with pediatric hip diseases are more comorbid than the general population and at risk of premature, secondary osteoarthritis, often leading to total hip arthroplasty (THA). We investigated whether THA confers an increased mortality in this cohort. Patients and methods — We identified 4,043 patients with a history of Legg–Calvé–Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), or developmental dysplasia of the hip (DDH) in the Swedish Hip Arthroplasty Register (SHAR) between 1992 and 2012. For each patient, we matched 5 controls from the general population for age, sex, and place of residence, and acquired information on all participants’ socioeconomic background and comorbidities. Mortality after THA was estimated according to Kaplan–Meier, and Cox proportional hazard models were fitted to estimate adjusted hazard ratios (HRs) for the risk of death. Results — Compared with unexposed individuals, patients exposed to a THA due to pediatric hip disease had lower incomes, lower educational levels, and a higher degree of comorbidity but a statistically non-significant attenuation of 90-day mortality (HR 0.9; 95% CI 0.4–2.0) and a lower risk of overall mortality (HR 0.8; CI 0.7–0.9). Interpretation — Patients exposed to THA due to a history of pediatric hip disease have a slightly lower mortality than unexposed individuals. THA seems not to confer increased mortality risks, even in these specific patients with numerous risk factors.

Reconstructive surgery in recurrent deformity (clubfoot relapse)

Introduction Recurrent clubfoot deformity may be due to either an imperfect initial correction, or a natural history of a severe disease. In the later, idiopathic clubfoot is uncommon. In the review we describe reconstructive surgery in recurrent deformity of idiopathic clubfoot. Material and methods Surgery may be justified at different age and according to the type of deformity. Different surgical approaches and their indications are exposed in the article. Results After Ponseti’s method application additional surgeries may be considered in recurrent clubfoot deformity which may represent 10 to 20 % of cases: second Achilles tenotomy, postero-lateral relapse, complete antero-medial and postero-lateral relapse, transfer of the anterior tibial tendon, correction of sequelae: metatarsus varus, residual equinus, residual rotation of the calcaneopedal unit. Conclusion Idiopathic equine varus clubfoot is a frequent condition. Well-codified management should lead to extremely favorable functional results. Unfortunately, some cases lead to a recurrence of the deformity. Surgical procedures are sometimes required. The goal is to avoid as much as possible arthrodesis and secondary degenerative arthritis.

Direct anterior approach for total hip arthroplasty using the "bikini incision".

The classic skin incision for direct anterior approach (DAA) total hip arthroplasty (THA) is usually placed over the belly of the tensor fasciae latae (TFL) muscle parallel to the axis of the lower extremity. In the "bikini incision" technique however, amore horizontal skin incision is used and placed parallel to the skin creases, which largely corresponds to the skin's tension lines to prevent hypertrophic scarring and optimize cosmetic outcomes. Primary or secondary osteoarthritis, femoral neck fracture, aseptic acetabular component loosening with sufficient bone stock and without the need for proximal extension of the approach, head and/or liner exchange. Complex primary or revision THA requiring extensile distal and/or acetabular exposure, revision with pre-existing longitudinal DAA incision, inguinal skin infection. The skin incision, located three fingerbreadths distal to the anterior superior iliac spine (ASIS), is orientated parallel to the groin crease. One third of the incision is medial and two thirds lateral to the ASIS. Subcutaneous dissection should only be performed in the lateral two thirds of the incision to protect the main branches of the lateral femoral cutaneous nerve (LFCN). The fascia lata is opened as far lateral over the muscle belly as possible to leave the LFCN untouched within its fascial sheet. The stepwise procedure consists of three key steps: capsular exposure, capsular release, and component insertion. The approach allows for an excellent 360° exposure of the acetabulum. The femur is aligned along the incision during femoral elevation and adduction. With this technique, DAA hip arthroplasty can be performed in aless-invasive way providing best possible functional and cosmetic outcomes. No restrictions in ambulation or range of motion. Deep vein thrombosis prophylaxis. In aprospective series of 532consecutive patients undergoing 613 primary THA with abikini-incision in 2017, a good clinical outcome with a2.3% incidence of wound-related problems was observed. In particular, obese patients can also benefit from the technique.

Chronic Pain in Patients with Rheumatoid Arthritis.

Chronic pain is highly prevalent in patients with rheumatoid arthritis (RA) and can cause various physical and psychological impairments. Unfortunately, the appropriate diagnosis of chronic pain syndromes in this population can be challenging because pain may be primary to RA-specific inflammation and/or secondary to other conditions, typically osteoarthritis (OA) and fibromyalgia (FM). This disparity further poses a clinical challenge, given that chronic pain can often be discordant or undetected with standard RA-specific surveillance strategies, including serological markers and imaging studies. In this review, we provide a robust exploration of chronic pain in the RA population with emphasis on epidemiology, mechanisms, and management strategies. Chronic pain associated with RA typically occurs in patients with anxiety, female sex, and elevated inflammatory status. Up to 50% of these patients are thought to have chronic pain despite appropriate inflammatory suppression, typically due to peripheral and central sensitization as well as secondary OA and FM. In addition to the standard-of-care management for OA and FM, patients with RA and chronic pain benefit from behavioral and psychological treatment options. Moreover, early and multimodal therapies, including non-pharmacological, pharmacological, interventional, and surgical strategies, exist, albeit with varying efficacy, to help suppress inflammation, provide necessary analgesia, and optimize functional outcomes. Overall, chronic pain in RA is a difficult entity for both patients and providers. Early diagnosis, improved understanding of its mechanisms, and initiation of early, targeted approaches to pain control may help to improve outcomes in this population.